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Contemporary Drug Problems 37/Summer 2010 Examining and understanding
the joint role of caffeine and
alcohol in facilitating violent
offending and victimization
BY JOSEPH B. KUHNS, TAMMATHA A. CLODFELTER,AND HEATHER Y. BERSOT The study draws attention to the importance of considering andcontrolling for caffeine and the interactive effects between caffeineand alcohol when investigating aggressive and violent behavior.
Various pathways between caffeine and alcohol consumption andaggression and violence are examined. Given recent changes inpreferences and availability of caffeine and energy drinks amonglicit and illicit substance users, this study argues for the importanceof focusing research attention on the role of caffeine, particularlywhen combined with alcohol, in facilitating violent outcomes.
Evidence suggests that both caffeine and alcohol are linked toaggression and violence and that both substances should beconsidered within the context of our efforts to manage the negativeconsequences of drugs. Caffeine, via energy drink consumption, maycontribute to violent offending and victimization in a variety ofways. Evidence suggests that caffeine/energy drink consumption ispopular among a subculture of toxic jock users, may motivate andfacilitate increased alcohol consumption particularly in late night-time economies, and can potentially contribute to disrupteddecision-making. Recent increases in caffeinated-productavailability, marketing, and consumption necessitate focusedresearch and policy attention. Many of these products are consumedwith alcohol and/or in late evening settings by individuals that arealready at increased risk for violent offending and victimization. KEY WORDS: Caffeine, energy drinks, aggression and violence,methodology. 2010 by Federal Legal Publications, Inc. Recently, there has been a substantial increase in the availabil-ity and marketing of caffeinated substances, including energydrinks, and increased use of these drinks along with alcohol.
These products are often marketed toward youth and youngadult populations, which also tend to report higher levels ofaggressive and violent behavior. This article draws attention tothis recent pattern of caffeine consumption, often in conjunc-tion with heavy drinking, explores the ways in which it mightimpact aggressive and violent behavior, and attempts toexplain the motivations behind this drug preference shift.
Caffeine and energy or stimulant drinks
Caffeine is the most widely consumed licit substance and isreadily available in a plethora of beverages, foods, and medi-cines (Bernstein, Carrol, Thuras, Cosgrove, & Roth, 2002;Rockett & Putnam, 2002; Griffiths, Juliano, & Chausmer,2003; Rogers, 2007; Ciapparelli et al., 2009). However, unlikeother legal psychoactive drugs, caffeine is not regulated by theFood and Drug Administration. Thus, users may assume thatcaffeine and caffeine-based products, such as the increasinglypopular energy or “stimulant” drinks, are rather benign andmany may be unaware of the quantity of caffeine found inthese commonly consumed drinks. For example, on average, an8 oz. cup of brewed coffee contains 85 mg of caffeine, a cup ofbrewed tea contains 40 mg, and most cola drinks contain atleast 24 mg (Griffiths et al., 2003). Dairy-derived products,such as coffee ice creams and flavored yogurts, provide anaverage of 50 mg of caffeine. Widely used over-the-countermedications, such as NoDoz® and Vivarin®, contain as muchas 200 mg of caffeine and are commonly used to diminishlethargy and sleepiness (Griffiths et al., 2003; Rogers et al.,2005). The average caffeine content of two tablets of commonpain relievers, such as Excedrin® and Midol®, is 64 mg or130 mg respectively (Griffiths et al., 2003). In recent years, highly-caffeinated energy drinks have becomefar more popular. Since the American debut of Austria’s Red Bull® in 1997, the number of energy drinks has increased toover 500 brands (Reissig, Strain, & Griffiths, 2008; Simon &Mosher, 2007). The United States has rapidly emerged as aglobal leader in consumption (Zenith International, 2007, ascited in Reissig, Strain, Griffiths, 2008). In 2006, energy drinksales exceeded $500 million (Miller, 2008a).
Consisting of caffeine, sugar, taurine, vitamins, and herbalingredients such as ginkgo biloba and ginseng, the seeminglyvigor-enhancing properties of energy drinks are appealing tomany younger consumers (Miller, 2008a; 2008b). Indeed, thetypical 8 oz energy drink contains 80 mg of caffeine (althoughsome brands may contain several times that amount) which iscomparable to one strong cup of coffee or two 12 oz. caffeinatedsoft drinks (Malinauskas, Aeby, Overton, Carpenter-Aeby, &Barber-Heidal, 2007). Many energy drink manufacturersinclude various natural ingredients (including flavoring fromcoca leaves) in their recipes in order to be classified under the1994 Dietary Supplement Health and Education Act, whichallows them to exceed caffeine content limits. In fact, someenergy drinks contain 150-300% of the amount of caffeinethat the FDA allows in soft drinks (McCluster, Goldberger, &Cone, 2006; see also Marczinski & Fillmore, 2006).
Continued concerns that are raised from the legal and medicalcommunities, as well as the public, have so far failed tochange the current non-regulation status (Ari Kapner, 2004;Reissig et al., 2008).
Although the debate over whether caffeine and energy drinksshould be regulated persists, the FDA recently notified 30manufacturers of caffeinated alcoholic beverages that it willbegin to explore the safety and legality of their products(FDA, 2009a, 2009b). Caffeine has only been approved as anadditive in soft drinks, which raises the question of how safealcoholic beverages containing the substance are and whethersuch products should legally be manufactured. According tothe Federal Food, Drug, and Cosmetic Act, “a substance addedintentionally to food (such as caffeine in alcoholic beverages) is deemed ‘unsafe’ and is unlawful unless its particular use hasbeen approved by FDA regulation or the substance isGenerally Recognized As Safe (GRAS)” (FDA, 2009a). Inorder for a substance to be considered GRAS, scientificexperts must determine that it can be safely consumed at theconcentration level included in a particular food product. Assuch, the FDA has requested that companies provide evidencethat their caffeinated alcoholic beverages have been deemedGRAS. If a manufacturer fails to satisfy the FDA’s require-ments, effort may be undertaken to remove their product(s)from store shelves (FDA, 2009a).
Regulation may be particularly important because the extantbody of literature on energy drinks suggests that the primarygroup of users is comprised of teenagers and young, or emerg-ing, adults. Identifying a particular type of user based on fre-quency of use, such as recreational use or chronic use, has notyet been subjected to empirical inquiry. However, it is impor-tant to consider demographic preferences in substance choice.
According to a recent study, 31% of 12 to 17-year-olds regular-ly consumed energy drinks. However, among those betweenthe ages of 18 to 24 years, 34% indicated that they recurrentlyconsumed such beverages. After the age of 25, the percentageof users notably decreased (Simon & Mosher, 2007).
Most American adults and many children regularly consumecaffeine. Despite the fact that caffeine is a licit substance com-monly found in beverages, foods, and medicines, any individ-ual who ingests such products could theoretically be consid-ered a drug user (Griffiths et al., 2003). Researchers have alsobegun to classify caffeine consumers based on personalitytraits, although some studies indicate that personality is not aprimary factor in determining who is likely to be a caffeineuser (Liguori et al., 1999; Brice & Smith, 2002; Hewlett &Smith, 2006a, 2006b). According to Hewlett and Smith (2006a),personality is a stable and shared characteristic among con-sumers and nonconsumers alike. However, other researcherssuggest that some personality traits are correlated to caffeine use (Jones & Lejuez, 2005; Gurpegui et al., 2007). For exam-ple, Gurpegui and colleagues (2007) determined that individ-uals with an interest in novelty-seeking are more likely to reg-ularly consume caffeinated products.
Caffeine users may also be classified according to a number ofpsychiatric syndromes identified both in the Diagnostic andStatistical Manual of Mental Disorders (DSM-IV-TR) and theWorld Health Organization’s International Classification ofDiseases (ICD-10) (American Psychiatric Association, 1994;Griffiths et al., 2003; World Health Organization, 2008). Thesediagnoses include caffeine intoxication, caffeine dependence,caffeine-induced sleep disorder, caffeine-induced anxiety dis-order, and caffeine withdrawal (Griffiths et al., 2003). Alongthese lines, the 2007 Annual Report of the American Associ-ation of Poison Control Centers documented 5,448 caffeine-related calls to poison centers, of which 4,183 were single drugexposure events (i.e., no other drugs were involved). Sixty per-cent of the callers for whom age was recorded were 19 years oldor younger, 1,573 of these events were categorized as “inten-tional” uses, and 1,561 of the users were medically treated inhealth care facilities. Over a third (36%) of these events wasconsidered moderate or major in seriousness, including onedocumented death (Bronstein et al., 2008; Table 22B).
Exploring pathways between caffeine consumption
and aggression or violence
The specific role that caffeine may play in facilitating aggres-sive and violent behavior has been previously explored inhumans and in animals (Peters, 1967; Cherek, Steinberg, &Brauchi, 1983; Istvan & Matarazzo, 1984; Lubit & Russett,1984; Carmel, 1991). Yet, a substantial gap exists betweenpast and current research efforts, and the cumulative body ofresearch indicates a need to further investigate this connectiongiven substantial recent increases in caffeine availability andconsumption.
The links between caffeine and aggression or violence can beexplored across various perspectives. First, the associationbetween caffeine and aggression might be examined within asubcultural context through the identification of specific usersand observations of their behaviors, activities, and associa-tions. Second, caffeine contains specific pharmacological prop-erties which may directly or indirectly contribute to aggressivereactions, behaviors, and victimization, particularly for thosewho are routinely involved in late-night activities that placethem at increased risk for involvement in violence. Third, someresearch is exploring the link between caffeine consumptionand cognitive impairments caused by neurobiological dysfunc-tion. These impairments may impact and interrupt decisionmaking. Finally, the potential links between caffeine and alco-hol consumption, night-time economies/activities, and increasedrisk for violent offending and victimization might be consid-ered. While these bodies of research continue to evolve, each ofthese perspectives offers some insight into the potential directand indirect relationships between caffeine consumption, caf-feine and alcohol consumption, and involvement in, or risk of,aggression and violent behavior.
To understand the potential pathways between caffeine and aggressive and violent behavior, it may be helpful to consider the subculture from which users emerge. Traditionally, a sub- culture encompasses certain symbols and a shared sense of values and behavioral norms (Golub, Johnson, & Dunlap,2005). To illustrate, consider a group of teenagers who gatherto smoke marijuana. The “youths may insist on smoking theirmarijuana in a blunt, drink 40-ounce bottles of malt liquor, lis-ten to rap music, wear baggy pants, define marijuana as not adrug, and socialize mainly with other blunt smokers” (Golubet al., 2005, p. 219). While past empirical investigations haveprincipally explored illegal substances such as marijuana,cocaine, and ecstasy within a drug subcultural context, fewstudies have considered licit substances including caffeine.
Some suggest that this is, in part, because a significant portionof the population regularly ingests caffeine, and consumption of caffeine often persists throughout adulthood (Golub et al.,2005).
One potential subculture of caffeine users includes those whoidentify themselves according to their involvement in sports(Miller, Melnick, Farrell, Sabo, & Barnes, 2006; Miller, 2008a).
The use of both licit and illicit drugs among athletes, rangingfrom high school team members to professionals, has been wide-ly documented (Ambrose, 2004; Green, Uryasz, and Petr, 2001;McDuff & Baron, 2005). In one particular study, elite athletesengaged in “stimulant stacking,” which involved ingesting inexcess of 500 mg of caffeine a day, along with consuming con-siderable dosages of nicotine and ephedrine or amphetamine(McDuff & Baron, 2005). Interestingly, to counteract the stimu-lants’ effects, many athletes also used alcohol (McDuff & Baron,2005), a common poly-drug situation to be discussed later.
Although research on energy drink consumers is still fairlylimited, a recent study offers a demarcation of one type ofenergy drink user emerging from the sports-related subculture,referred to as a “toxic jock” (Miller, 2008a, 2008b, 2009).
Based on the perceptions among males and females, thetypical toxic jock is a male, college undergraduate who self-identifies as a jock, engages in risk-taking behavior, andembodies traditional masculine characteristics. While investi-gators in the past have employed the term “athlete” and thecolloquial idiom “jock” interchangeably, researchers haverecently begun to note the distinction between the two as theyare individually and socially constructed in contemporarysociety (Miller, 2008a, 2009; Miller & Hoffman, 2009). Whileboth may share an interest in sports, their motivation and goalsdiffer considerably. Indeed, the disciplined athlete is involvedin pro-social activities and a variety of physical wellness pur-suits. In contrast, the jock may be engaged in risk-seeking,violent behavior, and only a few high-profile sports (Miller &Hoffman, 2009). Thus, to the toxic jock, energy drinks moreclosely represent his lifestyle needs and preferences (Miller,2008a).
Marketing researchers have been quick to study the demo-graphics of energy drink users and to measure consumptionpatterns. If the toxic jock is the average energy drink consumer,perhaps it is not surprising that marketing strategies emphasizeinvolvement in high-risk and potentially illicit activities(Miller, 2008b). Indeed, one need only consider the increasing-ly provocative brand names of energy drinks currently on themarket. Alluding to both illegal and promiscuous activities,some of the latest energy drink names (available in differentcountries) include Cocaine®, Bong Water®, Crunk®,Playboy®, Pussy® and Sex Drive® (Miller, 2008a). To market these drinks, ads are strategically purchased andbroadcast during television shows geared for teen and youngadult male viewers. For example, in one large southeasternAmerican city, ads for the energy drink Vault® are broadcastduring teen and young adult male-oriented shows such as FamilyGuy, American Gladiator, and major sports events (L. Zannino,personal communication, September 27, 2009). Websites areanother medium used to effectively market to teens and youngmen. As one example, the Website for Monster Energy drinkwelcomes visitors with the following rage-inducing rhetoric: Tear into a can of the meanest energy supplement on the planet,MONSTER energy. We went down to the lab and cooked up a dou-ble shot of our killer energy brew. It’s a wicked mega hit that deliv-ers twice the buzz of a regular energy drink. The MONSTER packsa vicious punch but has a smooth kick ass flavor you can reallypound down. So when it’s time to unleash the beast within, grab aMONSTER and GO BIG! (Monster Energy, 2008).
Although some energy drink brand names, such as Red Bull,do not explicitly imply illicit or high-risk sexual or violentbehavior, they are nevertheless decisively marketed to appealto younger, image-conscious consumers (Jackson et al., 2000). This global marketing strategy has also been employed to encourage co-consumption of alcohol and energy drinks. In Britain, Red Bull was estimated to increase alcohol sales by 20% in pubs and clubs (Jackson, Hastins, Wheeler, Eadie, & Mackintosh, 2000). Further, advertisers in Africa have begunto market energy drinks and premixed concoctions includingalcohol “not as commodities but as concepts, experiences andlifestyles” that are alluring to youth (Odejide, 2006, p. 28).
Within the United States, caffeinated alcoholic beverages weremarketed as “trendy cocktails” designed to meet the party-going needs of college students (Marczinski & Fillmore, 2006).
Combining alcohol with energy drinks, however, may increasethe likelihood that an individual will consume greater quanti-ties of alcohol. In addition to consuming more alcohol, collegestudents who mix alcohol with energy drinks were more likelyto be involved in alcohol-related injuries. More importantly,those who consumed a combination of alcohol and energydrinks showed a propensity for taking advantage of others sex-ually and for provoking and engaging in physical altercations(Reissig et al., 2008; Miller, 2008a, 2008b). As a result, thepotential direct or indirect causal relationship between caf-feine (via energy drink consumption and perhaps in combina-tion with alcohol) and aggression and violence should be con-sidered in future research, even if caffeine by itself may notrepresent a significant or primary cause of aggression or vio-lence (Griffiths et al., 2003). While alcohol alone affects motor coordination and visual reac-tion time, recent studies indicate that caffeine combined withalcohol may reduce the perceived impairment effect, despite thefact that impairment likely exists. Interestingly, these studiesfound that breath concentration of alcohol is not affected by theco-ingestion of caffeine. (Ferreira, de Mello, Pompeia, & deSouza-Formigoni, 2006; Marczinski & Fillmore, 2006). In addi-tion, caffeine may augment an individual’s real or perceived tol-erance for alcohol (Fillmore, 2003; Marczinski & Fillmore,2006; Ferreira et al., 2006). As with the increased need fornicotine, the co-ingestion of caffeine and alcohol may thereforefacilitate increased alcohol consumption, which may thendirectly or indirectly lead to aggression and violence or evenself-induced harm (including excessive caffeine intoxication).
While some energy drink users are more likely to engage inactivities such as smoking or illegal drug use, the majoritycombine these drinks with alcohol (Reissig et al., 2008). Arecent study revealed that nearly one quarter (24%) of collegestudents consumed a mixture of alcohol and energy drinkswithin the past month (O’Brien et al., 2008). Within anothersample of 469 college students, nearly half (49%) of those whoregularly combined alcohol and energy drinks used more thanthree energy drinks to create cocktails such as Vodka RedBulls, Jager Bombs, and the like (Malinauskas et al., 2007).
Recognizing this consumption pattern, several brewing compa-nies manufactured premixed caffeine-alcohol combinationdrinks. In response, eleven State Attorneys raised legal chal-lenges to these sales, and Anheuser-Busch, one of the largestbeer brewers in America, agreed to cease production of pre-mixed drinks (Idaho Office of the Attorney General Website, ascited in Reissig et al., 2008). As noted previously, the FDA hasrecently launched an investigation into the safety and legalityof caffeinated alcoholic beverages that are still being manufac-tured. Nevertheless, such mixtures remain available in manycountries and are routinely served in bars and restaurants. A separate body of research has started to explore the role of substances in disrupting decision-making processes. The cog- nitive process of decision making involves several distinct, but interrelated, stages (Ernst & Paulus, 2005; Schoenbaum, Roesch, & Stalnaker, 2006; Fishbein et al., 2005; Bechara &Damasio, 2002). Decision making occurs when individualsevaluate viable options, determine a preference, carry out anaction in response to the selected preference, and reflect uponthe experience of the outcome (Ernst & Paulus, 2005; Clark &Robbins, 2002; Schoenbaum et al., 2006). Calculating theexpected value of viable options is expressed as the root ofdecision making and is embraced across social science disci-plines including criminology, economics and neurobiology(Akers, 2000; Friedman, 2002). This conceptualization of rational choice has been extended by acknowledging thatexternal factors can limit decision making outcomes (Cromwell & Olson, 2006; Shover & Honaker, 2006).
Neurobiological research has progressively examined theintricacies of these relationships and attempted to identifysome of the external factors that disrupt the neurologicalactivities.
A significant amount of research has examined cognitive dis-ruptions attributed to external factors such as consumption andabuse of psychoactive substances (Ernst & Paulus, 2005;Shoenbaum et al., 2006). Much of the current research focus-es specifically on alcohol (Attwood, Ohlson, Benton, Penton-Voak, & Munafo, 2009; Craig, Attwood, Benton, Penton-Voak, & Munafo, 2009; Reynolds, Richards, & Wit, 2006) andillicit psychoactive substances including opiates (Brand, Roth-Bauer, Driessen, & Markowitsch, 2008; Clair et al., 2009),ecstasy (Fox, Parrott, & Turner, 2001; Hoshi, Pratt, Mehta,Bond, & Curran, 2006), or combinations of various illegalsubstances (Clark, Roser, Robbins, & Sahakian, 2009; Goldsteinet al., 2004; Verdejo-Garcia et al., 2007). Meanwhile, littleresearch has examined the most commonly used and legalpsychoactive substances. Evidence regarding the direct impact of acute caffeine con-sumption on cognitive dysfunctions is scant. Most research inthis area connects caffeine, particularly during withdrawal, tovarious psychological states including anxiety, depression,and aggression (Lubit & Russett, 1984; Wilson et al., 2000;Rogers, 2007), but does not investigate the underlyingprocesses leading to these conditions. However, Majithia(2009) suggests that caffeine withdrawal facilitates a deple-tion of serotonin, which is often implicated in substance abuseresearch as a causal factor related to aggression.
Caffeine consumption has been shown to be inversely relatedto age (Ciapparelli et al., 2009), which corroborates findingsthat the marketing of energy drinks mixed with alcohol is tar-geted to younger consumers (Jackson et al., 2000). While it iscurrently unclear whether caffeine or energy drinks directly impair cognitive functioning, the role of alcohol in negativelyaffecting thinking and behavior is widely supported, particu-larly among individuals with alcohol abuse or dependencediagnoses (Kuhns & Clodfelter, 2009; Attwood et al., 2009;Reynolds et al., 2006; Schuckit, 2009; Vik, Cellucci, Jarchow,& Hedt, 2004). Therefore, it would be prudent to consider theinteractive effects of energy drinks (caffeine) and alcohol con-sumption on neurological disruptions and decision making infuture research efforts.
Risk for involvement in violent offending or victimization might also increase simply as a function of consumption pat- terns, settings, and situations. Since caffeine may increase tol- erance or impact the perceived effects of alcohol, it stands to reason that more alcohol might be consumed within a specificdrinking episode if caffeine is also consumed simultaneously.
Again, Red Bull was estimated to have increased alcohol salesby 20% in pubs and clubs in Britain (Jackson et al., 2000).
Further, the time and length of the consumption process mightresult in increased risk for involvement in violence. The rela-tionship between late night and weekend drinking andincreased risk of involvement in violent offending and victim-ization has already been documented in Britain (Finney, 2004;Donkin & Birks, 2007) and in other areas of the world, partic-ularly among 18 to 24-year-old males (Finney, 2004), but alsoincreasingly among females within that age group (Forsyth,2006). Many of these late night or all-night partying and con-sumption events occur in and around bars (Home Office,2009), restaurants, sporting events, raves, college campuses,and other areas or situations that are associated with night-time economies. Historically, younger males are most likely tobe involved in violence as both offenders and victims (Donkin& Birks, 2007; Kuhns, 2005) and that same demographic sub-group is both the target audience for energy drink marketingcampaigns and the major consumers of energy drinks. As aresult, the widespread introduction of energy drinks (caffeine)into the pub and bar scene may generate increased concerns with alcohol consumption among younger males and femalesinteracting in late night settings and for longer periods of time.
Such situations, while inherently risky, might also offeropportunities for situational crime prevention efforts (Clarke& Eck, 2007).
Summary and conclusion
As the most widely used and readily available stimulant, caf-feine has received considerable research attention with respectto its positive and negative health consequences. However,criminologists have generally focused significantly moreresearch attention on alcohol and illicit drugs when exploringdrug-violence relationships. As a result, there may be a ten-dency to dismiss, overlook, or otherwise ignore the potentialconsequences of daily or excessive caffeine consumption onbehavioral patterns, poly-drug use, decision making, and late-night experiences and exposure.
Past studies have documented weak relationships betweenalcohol and caffeine consumption (Istvan & Matarazzo, 1984).
However, recent trends in caffeinated energy drink develop-ment, availability, production, marketing, and consumption ofalcohol/caffeine combination drinks requires researchers topay closer attention to this relationship and consider theimpact as an alternative explanation of, or a contributor to,violent outcomes. Caffeine and energy drinks may be particu-larly attractive to certain aggressively predisposed users (toxicjocks), may interact with alcohol and other drugs which dofacilitate aggression and violence, may impact or impair deci-sion making processes, and may be linked to specific geo-graphical locations and timeframes (nightlife) that representinherently risky settings.
Past research has suggested that poly-drug users tend to scorehigher on measures of aggressiveness and hostility (McCormick& Smith, 1995). To the extent that late night partying (includ- ing alcohol and caffeine coconsumption) includes increasedexposure to, experimentation with, and involvement in otherlicit and illicit drug use, potential concerns with violentoffending and victimization may escalate. The anticipatedeffects of caffeine on subsequent aggression within an experi-mental setting has been documented (Taylor, O’Neal, Langley,& Butcher, 1991), suggesting that aggressively-motivatedmales and females who “think” that energy drinks can impacttheir behavior may simply act accordingly, regardless of anypharmacological effect or lack thereof. In addition, some con-sumers of energy drinks use these beverages so that they canremain alert and subsequently drink more alcohol (Safefood,2009). Regardless of whether the caffeine does or does notimpact real or perceived intoxication levels, the net result maybe that young males and females ultimately continue drinkingfor longer periods during late-night hours when offending andvictimization are already more likely to occur. Again, thesocial settings for many of these events are already inherentlyrisky.
In Britain, some evidence suggests that a “culture of intoxica-tion” is recently evolving as a function of several factors.
First, there appears to be growing acceptance that use of psy-choactive substances is considered “normal” within late-nightdance and music-oriented environments. Second, there havebeen substantial changes in development and marketing strate-gies within the alcohol industry, including increases in alcoholcontent in some beverages. Third, evidence suggests broaderacceptance, across a larger segment of the population, of bingedrinking and drunkenness as routine expectations of late-nightsocialization and leisure activity. Finally, there are perceivedshifts in societal regulations and restrictions on hedonisticbehavior accompanied by changes in tolerance and acceptanceassociated with bounded, yet determined, alcohol and otherdrug consumption (Meashan & Brain, 2005). Arguably, caf-feine and energy drinks are contributing to, and perhaps fur-ther fueling, this culture of intoxication.
To the extent that regulations, laws and policies are directedtoward managing the consequences of drug use, it is importantto consider caffeine and energy drinks within that context.
Historically, drug enforcement efforts and resources havemostly focused on alcohol and illicit substances, based in parton the psychopharmacological, economic-compulsive, andsystemic relationships to violence (Goldstein, 1985). Meanwhile,the numbers of deaths attributed to two licit drugs (alcoholand nicotine, via tobacco) far exceed those associated with allillicit drug use combined (Mokdad, Marks, Stroup, &Gerberding, 2004). Again, in 2007 there were 5,448 caffeine-related calls to poison centers in the United States, of which4,183 were single drug exposure events (i.e., no other drugswere involved; Bronstein et al., 2008).
These early warning signs can hopefully serve as catalysts formore careful consideration of the direct and indirect conse-quences of widespread availability, marketing, acceptance,and consumption of caffeinated beverages, particularly whencombined with alcohol. The failure to act in a timely mannerwith respect to the known consequences of tobacco resulted inmillions of needless deaths in the United States. Alcohol con-tinues to contribute substantially to the annual death toll. Itwould be equally irresponsible if we failed to pay close atten-tion to the potential consequences of a highly-caffeinated,alcohol-intoxicated, young male and female population thatspends considerable late-night hours interacting in environ-ments that are inherently risky.
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