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Flavored Alcoholic Beverage Use, Risky Drinking Behaviors, and Adverse Outcomes Among Underage Drinkers: Results From the ABRAND Study Alison Burke Albers, PhD, Michael Siegel, MD, MPH, Rebecca L. Ramirez, MPH, Craig Ross, PhD, MBA, William DeJong, PhD, and David H. Jernigan, PhD
Alcohol continues to be the most commonly used drug among youths in the United States and is responsible for more than 4300 annual deaths among underage drinkers.1 Approximately 33% of eighth graders and 70% of 12th graders have consumed alcohol, and 13% of eighth graders and 40% of 12th graders drank during the past month.2 Close to 200 000 emergency department visits by persons younger than 21 years are reported annually for injuries and other conditions linked to alcohol.3 An important trend in underage drinking is the popularity of flavored alcoholic beverages (FABs).4---12 Despite their popularity, little is known about associations between FAB consumption, risky drinking behaviors, and related harms among underage drinkers. FAB brands can be classified into 3 categories: malt-based beverages; spirits-based, premixed- or ready-to-drink cocktails; and supersized alcopops.4 Although these products are widely classified as FABs, distinctions between them are important because these beverages differ in serving size (e.g., the supersized alcopops can contain 2 to 3 times the alcohol volume of other brands) and average alcohol content by volume (malt beverages, 7.8%; premixed- or ready-to-drink cocktails, 14.2%; supersized alcopops, 10.8%).4 We used ABRAND (Alcohol Brand Research among Underage Youth) data collected by GfK Knowledge Networks13 to analyze the brands of alcoholic beverages a national sample of youth drinkers aged 13 to 20 years reported consuming and found that nearly half of young drinkers (n = 515) had consumed FABs in the past 30 days.4 These results roughly matched those of the 2012 Monitoring the Future report, which found that more than half (57.5%) of students in grades 8, 10, and 12 who reported past 30-day alcohol use had consumed at least 1 FAB during that time.2 The ABRAND data also
Objectives. We examined associations between consumption of different types of flavored alcoholic beverages (FABs) and risky drinking and drinkingrelated harms among underage drinkers. Methods. For the Alcohol Brand Research among Underage Youth study, we applied multivariable logistic regression analyses to data from underage drinkers (n = 1031, aged 13–20 years), recruited from a national Internet panel in 2011 to 2012, to estimate associations between consumption of malt-based drinks; spirits-based, premixed- or ready-to-drink cocktails; and supersized alcopops, alone or in combination, and alcohol-related outcomes. Results. After adjustment for confounding variables, the exclusive consumption of alcopops was associated with episodic heavy drinking (odds ratio [OR] = 4.35; 95% confidence interval [CI] = 1.24, 15.31; P < .05) and alcohol-related injuries (OR = 6.25; 95% CI = 1.34, 29.10; P < .05). Exclusive consumption of cocktails was associated with episodic heavy drinking (odds ratio [OR] = 2.61; 95% CI = 1.26, 5.41; P < .05) and injuries requiring medical attention (OR = 6.50; 95% CI = 2.09, 20.17; P < .001. Exclusive consumption of 2 or more FABs was associated with episodic heavy drinking (OR = 2.78; 95% CI = 1.25, 6.16; P < .05), fighting (OR = 3.30; 95% CI = 1.46, 7.47; P < .001), and alcohol-related injuries (OR = 2.83; 95% CI = 1.43, 5.58; P < .001). Conclusions. FABs present an emerging public health problem among youths. (Am J Public Health. 2015;105:810–815. doi:10.2105/AJPH.2014.302349)
showed that 43% of drinkers aged 13 to 15 years, 48.9% of those aged 16 to 18 years, and 52% of those aged 19 to 20 years consumed FABs.4 Consumption prevalence was greatest for malt beverages (33.8%), followed by premixed- or ready-to-drink cocktails (23.9%) and supersized alcopops (8.6%). Almost one quarter of respondents (24.5%) had consumed at least 1 FAB during a heavy-drinking episode (defined as consuming ‡ 5 drinks in a row).4 FABs’ high alcohol content, low price, sweet flavoring, attractive packaging, and targeted marketing strategies have caused concern that FAB consumption might disproportionately contribute to alcohol-related emergency department visits by underage drinkers.5 One case study found that consumption of supersized alcopops such as Four Loko contributed to alcohol-related emergencies involving drinkers as young as 13 years.14
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We used the ABRAND sample of underage drinkers to examine the relationship between consumption of different types and combinations of FABs and risky drinking behaviors and adverse outcomes among youths aged 13 to 20 years.
METHODS Here we provide a brief overview of the study sample and data collection procedures; complete details have been published elsewhere.15 In December 2011 through May 2012, we used a prerecruited, randomly selected Internet panel maintained by GfK Knowledge Networks of Palo Alto, California,13 to obtain a sample of 1031 youths aged 13 to 20 years who had consumed at least 1 alcoholic drink during the past 30 days. We conducted an online, self-administered survey to learn what brands of alcohol respondents had
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consumed during the past 30 days, the number of days on which they consumed each brand, and the typical number of drinks of each brand they consumed on those days.
Sample Knowledge Networks used its established national Internet panel to recruit adolescents aged 13 to 17 years and young adults aged 18 to 20 years via e-mail to participate in our Internet survey. To identify respondents aged 13 to 17 years, the network asked adult panelists whether they had children in that age range who could be invited, with parental permission, to participate in a survey. The network randomly selected 1 youth from each household. If parental consent was given, Knowledge Networks e-mailed the youth an invitation to participate in the survey. The sample of respondents aged 13 to 17 years was representative of the households in the national Internet panel. Panelists aged 18 to 20 years received an e-mail invitation from Knowledge Networks that did not indicate that the survey concerned alcohol consumption. Panelists who agreed to participate in the survey received an e-mail message containing a link to a secure Web site, which presented a screening questionnaire that determined whether the panelist consumed alcohol in the past 30 days and was thus eligible for the survey. All participants who completed the online consent form and survey received a $25 gift credited to their panel account. The response rates were 43.4% for panelists aged 18 to 20 years and 44.4% for those aged 13 to 17 years. We dropped a single respondent who reported drinking more than 15 drinks per day and more than 20 different alcohol brands. This resulted in a final sample of 1031 individuals: 41.5% were male; 11.4% were aged 13 to 15 years; 44.7% were aged 16 to 18 years; 43.9% were aged 19 to 20 years; 57.4% were White, non-Hispanic; 20.8% were Hispanic; 12.2% were Black; and 9.6% were other. Frequency of alcohol consumption in the past 30 days was 1 day (28.6%), 2 to 3 days (29.9%), 4 to 7 days (20.1%), and 8 or more days (21.4%). Approximately half the sample (49.7%) reported episodic heavy drinking (consuming ‡ 5 drinks in a row) in the past 30 days.
To assess possible nonresponse bias, we compared 18- to 20-year-old respondents and nonrespondents on basic demographic factors; we used the v2 test to assess the significance of observed differences. Nonrespondents were slightly older (P < .05), but similar in gender (P = .41), and were more likely to be Black (P < .001), to come from lower-income households (P < .01), and to have lacked Internet access prior to enrolling with Knowledge Networks (P < .001). We observed no significant differences by region (P = .11).
Survey Instrument and Measures The survey determined brand-specific alcohol consumption among underage drinkers for 898 major brands of alcohol, including 62 FABs. Our previously published study identified the types of beverages considered to be FABs: (1) malt-based flavored beverages (e.g., Bacardi malt beverages; n = 10); (2) spirits-based, premixed- or ready-to-drink cocktails (e.g., Jack Daniel’s cocktails; n = 44); and (3) supersized alcopops, which are sold in 16-ounce or larger containers and have at least 10% alcohol by volume (e.g., Four Loko; n = 8).4 These distinctions are important because, although all of these brands are classified as FABs, they differ in serving size and average alcohol content by volume.4 None of the FABs we analyzed contained caffeine. The complete list of all brands classified under these 3 categories has been published elsewhere.4 We used the National Institute on Alcohol Abuse and Alcoholism’s definition of a standard drink, which contains 14 grams of pure alcohol,15 and the average alcohol content of the 62 FAB brands to define 1 FAB standard drink as 8.5 ounces. To help respondents accurately report the number of standard drinks they consumed, the survey provided a visual aid with pictures of various types of alcoholic beverages and the number of ounces per standard drink for each type (a 12-ounce can of beer, an 8.5-ounce bottle of a FAB, a 1.5ounce shot of liquor, and a 5-ounce glass of wine). This picture was available on each page of the survey, and instructions reminded respondents of the volume size representing 1 standard drink as they answered questions about each type of alcoholic beverage. Beverages and risky behaviors. We determined prevalence estimates for 4 mutually
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exclusive FAB user categories: (1) FAB consumers who drank malt beverages exclusively (n = 176), (2) FAB consumers who drank premixed- or ready-to-drink cocktails exclusively (n = 102), (3) FAB consumers who drank supersized alcopops exclusively (n = 23), and (4) FAB consumers who used any combination of 2 or more FAB categories exclusively (n = 198). We compared each of these groups to participants who did not consume any FABs (n = 532). We assessed 4 primary outcome measures related to risky drinking behaviors: (1) the average number of drinking days per month, (2) the average number of drinks per day, (3) the average total number of drinks per month, and (4) episodic heavy drinking, defined as consuming 5 or more drinks in a row. Adverse outcomes related to drinking. We examined 3 primary adverse outcomes in the past 12 months: (1) fighting during or after drinking, (2) sustaining an alcohol-related injury, and (3) having an alcohol-related injury seen by a medical professional. Specifically, respondents were asked, “During the past 12 months, how often did you get into a physical fight while or after drinking?” We used responses to this question to create a dichotomous indicator of any fighting versus no fighting during the past 12 months. Respondents were also asked, “During the past 12 months, how often did you have an injury where any part of your body was hurt while or after drinking?” We used responses to this question to create a dichotomous indicator of any injury versus no injury. The respondents who reported an injury were next asked, “Of the times when you were injured, how many of those times was the injury serious enough that a medical professional was consulted?” From this question, we created a dichotomous indicator of any injury requiring a medical consultation versus no injury. Control variables. We differentiated youths by age: (1) 13 to 15 years, (2) 16 to 18 years, and (3) 19 to 20 years. We categorized race/ ethnicity into 4 groups: Hispanic; Black, nonHispanic; White, non-Hispanic; and other, with White, non-Hispanic as the reference group. We categorized reported household income into 4 groups: (1) less than $15 000, (2) $15 001 to $39 999, (3) $40 000 to $99 000, and (4) $100 000 or more. We also controlled for gender.
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Respondents were also asked, “During the past 30 days, on how many days did you smoke cigarettes?” We created a dichotomous variable of any smoking versus no smoking at all during the past 30 days. Our models also included seat belt use as a covariate because it has been shown to be a strong correlate of general risk taking among youths. Respondents were asked, “How often do you wear a seat belt when you are riding in or driving a car?” We created a dichotomous indicator of always wearing a seat belt versus all other seat belt use. Our models also included the total number of drinks consumed per month.
Statistical Analyses To render the sample representative of the underlying population of youths aged 13 to 20 years, Knowledge Networks applied statistical weighting adjustments to account for selection deviations.16 These weights accounted for the different selection probabilities associated with the company’s random-digit-dialing and address-based sampling procedures, oversampling of minority communities, nonresponse to panel recruitment, and panel attrition. The poststratification weights adjusted for gender, age, race/ethnicity, census region, household income, home ownership status, metropolitan area, and household size, derived from demographic distributions from the Current Population Survey, conducted by the US Census Bureau.13,16 We conducted multiple logistic regression analyses for each of the 4 binary outcome variables—episodic heavy drinking, fighting, alcohol-related injury, and injury requiring medical attention—with adjustment for potential differences in population characteristics across the beverage categories: age, gender, race/ethnicity, income, smoking status, total number of drinks consumed per month, and general risk taking (seat belt use). These analyses examined the independent effect of drinking each type of FAB: (1) malt beverages exclusively, (2) premixed- or ready-to-drink cocktails exclusively, (3) supersized alcopops exclusively, and (4) exclusive use of any combination of 2 or more FAB categories. We used Stata SE version 12.1 (StataCorp LP, College Station, TX) for all analyses.
RESULTS The Venn diagram in Figure 1 illustrates the entire distribution of specific FAB usage among our young respondents. This shows that 176 youths reported drinking only malt beverages, 102 reported drinking only premixed- or ready-to-drink cocktails, and 23 reported only drinking supersized alcopops. In addition, 122 participants reported drinking both malt beverages and premixed- or ready-to-drink cocktails, 19 reported drinking both malt beverages and alcopops, and 19 reported drinking both premixed- or ready-to-drink cocktails and alcopops. An additional 38 youths reported drinking all 3 FAB types. In total, 198 youths reported drinking any combination of 2 or more FAB categories. As shown in Table 1, youths who reported exclusive alcopop use in the past 30 days drank significantly more days per month (mean = 9.1) than did exclusive malt beverage users (mean = 4.7), exclusive premixed- or ready-todrink cocktail users (mean = 4.8), and non--FAB users (mean = 4.7). Youths who reported exclusive use of any combination of 2 or more
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FAB categories in the past 30 days also drank on significantly more days per month (mean = 7.8) than did malt beverage users, premixed- or ready-to-drink cocktail users, and non---FAB users. We found no statistically significant differences in the average number of drinks per day among exclusive premixed- or ready-to-drink cocktail users (mean = 3.8), exclusive alcopop users (mean = 4.7), and combination FAB users (mean = 4.0). Users from these 3 groups reported significantly more drinks per day than did exclusive malt beverage users (mean = 2.9) and non---FAB users (mean = 3.1). The average total number of drinks in the past month was significantly higher among exclusive supersized alcopop users than among other categories of users (mean = 52.6 drinks for alcopop users, 35.2 for combination FAB users, 25.8 for exclusive premixed- or ready-to-drink cocktail users, 15.9 for exclusive malt beverage users, and 17.7 for non---FAB users). Youths who exclusively used premixed- or ready-to-drink cocktails or were combination FAB users also had a significantly higher average total numbers of drinks per month than did malt beverage users and non---FAB users.
Flavored malt beverage user only n = 176 n = 122
n = 19 n = 38
Premixed- or ready-to-drink cocktail user only n = 102
n = 19
Supersized alcopops user only n = 23
Note. This Venn diagram demonstrates the interaction of the use of flavored malt; spirits-based, premixed- or ready-to-drink cocktails; and supersized alcopops. FABs are defined as brands belonging to 1 of these 3 categories of alcoholic beverages. Supersized alcopops are sold in 16-ounce-or-greater containers and contain at least 10% alcohol by volume. The sample size of any combination of 2 or more FAB categories is n = 198.
FIGURE 1—Venn diagram of flavored alcoholic beverage (FAB) brand use among underage drinkers.
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TABLE 1—Prevalence of Risky Drinking Behavior Among Underage Exclusive Users of Different Types of Flavored Alcoholic Beverages (FABs): ABRAND Study, United States, 2011–2012 User Type
Drinking Days per Month, Mean (95% CI)
Drinks per Day, Mean (95% CI)
Total Drinks per Month, Mean (95% CI)
Episodic Heavy Drinkers, % (95% CI)
Non-FAB (n = 532)
4.7 (4.3, 5.2)
3.1 (2.8, 3.3)
17.7 (15.0, 20.4)
44.8 (40.5, 48.9)
Exclusively flavored malt beverages (n = 176)
4.7 (4.1, 5.4)
2.9 (2.5, 3.2)
15.9 (12.4, 19.4)
45.1 (37.7, 52.5)
Exclusively premixed- or ready-to-drink cocktails (n = 102) Exclusively supersized alcopops (n = 23)
4.8 (4.0, 5.6) 9.1 (5.5, 12.8)
3.8 (3.1, 4.5) 4.7 (2.9, 6.6)
25.8 (18.1, 33.6) 52.6 (30.3, 74.9)
69.6 (60.5, 78.6) 76.5 (57.8, 95.3)
Combination of FABs (n = 198)
7.8 (6.9, 8.8)
4.0 (3.6, 4.5)
35.2 (29.2, 41.2)
79.5 (73.4, 85.1)
Note. ABRAND = Alcohol Brand Research among Underage Youth; CI = confidence interval. FABs were categorized as (1) flavored malt beverages (n = 10); (2) spirits-based, premixed- or ready-todrink cocktails (n = 44); or (3) supersized alcopops, sold in 16-ounce-or-greater containers and containing at least 10% alcohol by volume (n = 8). Combination FAB users reported exclusive consumption of 2 or more FAB types.
Exclusive premixed- or ready-to-drink cocktail use, exclusive supersized alcopop use, and combination FAB use were significantly associated with episodic heavy drinking. Nearly 70% of premixed- or ready-to-drink cocktail users, about three quarters (76.5%) of alcopop users, and almost 80% of combination FAB users were episodic heavy drinkers, far more than the 45.1% of malt beverage users and 44.8% of non---FAB users who reported engaging in heavy-drinking episodes. Youths who exclusively consumed premixedor ready-to-drink cocktails or supersized alcopops and combination FAB drinkers had a higher proportion of adverse outcomes than did youths who consumed malt beverages exclusively or did not consume FABs at all (Table 2). Fighting was significantly more prevalent among premixed- or ready-to-drink cocktail users (22.8%), than among alcopop users (18.6%), malt beverage users (3.7%), and non---FAB users (8.6%). Drinking a combination of FABs was also significantly associated
with fighting (21.3%). Alcopop users were significantly more likely to report fighting than were malt beverage users but not non---FAB users. Slightly more than 50% of exclusive supersized alcopop users and 42.1% of combination FAB users reported alcohol-related injuries; 24.3% of exclusive premixed- or ready-todrink cocktail users, 14.1% of exclusive malt beverage users, and 14.4% of non---FAB users reported such injuries. A significantly higher proportion of premixed- or ready-to-drink cocktail users and combination FAB users had an alcohol-related injury requiring a doctor visit than did users of the other beverage categories: injuries sent 13.8% of premixedor ready-to-drink cocktail users, 8.2% of combination FAB users, 6.8% of alcopop users, and 1.3% of both malt beverage users and non---FAB users to the doctor. Table 3 shows the results from logistic regression models that examined the association between exclusive FAB use and adverse outcomes related to drinking, after adjustment
for age, gender, race/ethnicity, income, smoking status, total number of drinks consumed in the past month, and seat belt use. Use of premixed- or ready-to-drink cocktails, supersized alcopops, and any combination of 2 or more FABs was significantly associated with episodic heavy drinking. Premixed- or readyto-drink cocktail users were more than twice as likely as non---FAB users to engage in episodic heavy drinking (odds ratio [OR] = 2.61; 95% confidence interval [CI] = 1.24, 5.41; P < .05), and combination FAB users were nearly 3 times as likely as non---FAB users to engage in episodic heavy drinking (OR = 2.78; 95% CI = 1.25, 6.16; P < .05). Supersized alcopop users were more than 4 times as likely as non---FAB users to engage in episodic heavy drinking (OR = 4.35; 95% CI = 1.24, 15.31; P < .05). In the multivariable logistic model, only combination FAB use was associated with fighting: combination users were more than 3 times as likely as non---FAB users to
TABLE 2—Prevalence of Adverse Drinking-Related Outcomes Among Underage Exclusive Users of Different Types of Flavored Alcoholic Beverages (FABs): ABRAND Study, United States, 2011–2012 Fighting, % (95% CI)
Alcohol-Related Injury, % (95% CI)
Injury Requiring Doctor Visit, % (95% CI)
8.6 (6.1, 10.9) 3.7 (0.8, 6.5)
14.4 (11.2, 17.3) 14.1 (8.7, 19.4)
1.3 (0.3, 2.2) 1.3 (0.0, 3.0)
Exclusively premixed- or ready-to-drink cocktails (n = 102)
22.8 (14.3, 31.3)
24.3 (15.6, 33.0)
13.8 (6.8, 20.8)
Exclusively supersized alcopops (n = 23)
18.6 (1.4, 35.7)
50.7 (27.9, 73.4)
6.8 (0.0, 17.9)
Combination of FABs (n = 198)
21.3 (15.5, 27.1)
42.1 (34.9, 49.1)
8.2 (4.3, 12.0)
User Type Non-FAB (n = 532) Exclusively flavored malt beverages (n = 176)
Note. ABRAND = Alcohol Brand Research among Underage Youth; CI = confidence interval. FABs were categorized as (1) flavored malt beverages (n = 10); (2) spirits-based, premixed- or ready-todrink cocktails (n = 44); or (3) supersized alcopops, sold in 16-ounce-or–greater containers and containing at least 10% alcohol by volume (n = 8). Combination FAB users reported exclusive consumption of 2 or more FAB types.
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TABLE 3—Multivariable Logistic Regression of Flavored Alcoholic Beverage (FAB) Use Among Underage Drinkers: ABRAND Study, United States, 2011–2012 User Type
Episodic Heavy Drinking, AOR (95% CI)
Fighting, AOR (95% CI)
Alcohol-Related Injury, AOR (95% CI)
Injury Requiring Doctor Visit, AOR (95% CI)
Non-FAB (Ref; n = 532)
1.00
1.00
1.00
1.00
Exclusively flavored malt beverages (n = 176)
0.96 (0.49, 1.89)
0.42 (0.11, 1.69)
0.83 (0.32, 2.13)
0.42 (0.04, 4.69)
Exclusively premixed- or ready-to-drink cocktails (n = 102) Exclusively supersized alcopops (n = 23)
2.61* (1.26, 5.41) 4.35* (1.24, 15.31)
1.45 (0.40, 5.30) 0.76 (0.14, 4.09)
2.55 (0.91, 7.18) 6.25* (1.34, 29.10)
6.50** (2.09, 20.17) 1.86 (0.22, 15.66)
Combination of FABs (n = 198)
2.78* (1.25, 6.16)
3.30** (1.46, 7.47)
2.83** (1.43, 5.58)
2.90 (0.87, 9.68)
Note. ABRAND = Alcohol Brand Research among Underage Youth; AOR = adjusted odds ratio; CI = confidence interval. FABs were categorized as (1) flavored malt beverages (n = 10); (2) spiritsbased, premixed- or ready-to-drink cocktails (n = 44); or (3) supersized alcopops, sold in 16-ounce-or-greater containers and containing at least 10% alcohol by volume (n = 8). Combination FAB users reported exclusive consumption of 2 or more FAB types. Odds ratios adjusted for age, gender, race/ethnicity, income, smoking status, total number of drinks per month, and seat belt use. *P < .05; **P < .001.
engage in fighting (OR = 3.30; 95% CI = 1.46, 7.47; P < .001). Both exclusive alcopop use and combination FAB use were associated with alcohol-related injury (Table 3). Alcopop users were more than 6 times as likely as non---FAB users to report an alcohol-related injury (OR = 6.25; 95% CI = 1.34, 29.10; P < .05), and combination FAB users were nearly 3 times as likely as non---FAB users to report an alcohol-related injury (OR = 2.83; 95% CI = 1.43, 5.58; P < .001). Premixed- or ready-to-drink cocktail users were nearly 7 times as likely as non---FAB users to report an injury requiring a doctor visit (OR = 6.50; 95% CI = 2.09, 20.17; P < .001). We detected no statistically significant relationship between alcopop use or combination FAB use and reporting an alcohol-related injury requiring a doctor visit.
DISCUSSION We found that underage drinkers who reported 3 types of exclusive FAB use—premixedor ready-to-drink cocktails only, supersized alcopops only, and any combination of 2 or more FABs—consumed, on average, more drinks per day; drank on more days per month; and were likelier to engage in episodic heavy drinking. These results were particularly striking among alcopop users, who consumed double the total number of drinks per month consumed by users of premixed- or ready-to-drink cocktails and triple the total number of drinks consumed by malt beverage users and non--FAB users. A remarkable 69.6% of premixedor ready-to-drink cocktail users, 76.5% of
alcopop users, and 79.5% of combination FAB users reported episodic heavy drinking; only approximately 40% of malt beverage users and non---FAB users reported binge drinking. Alcopop users were 4 times as likely as non--FAB users to drink at this level, after adjustment for a host of variables. Both users of premixedor ready-to-drink cocktails and combination FAB users were nearly 3 times as likely as non---FAB users to report episodic heavy drinking. Supersized alcopop and combination FAB users were also significantly more likely than non---FAB users to sustain alcohol-related injuries; alcopop users’ odds were fully 6 times as high as for the referent group, underage drinkers who did not consume FABs. Combination FAB users were significantly more likely than non---FAB users to engage in fighting. Premixed- or ready-to-drink cocktail users were more than than 6 times as likely as non--FAB users to sustain an alcohol-related injury serious enough to require a medical professional consultation. Our findings were similar to those of other research indicating that mixing energy drinks with alcohol is associated with greater risk for both adverse outcomes of drinking and increased risk-taking behaviors.17---20 The most recent study found that adolescents who consumed caffeinated alcoholic beverages, particularly premixed caffeinated alcoholic beverages or self-mixed alcoholic beverages with energy drinks or energy shots, were at an increased risk of adverse outcomes, including episodic heavy drinking, fighting, and alcoholrelated injury.17
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To the best of our knowledge, ours was the first study to examine distinctions among the 3 major types of FAB products, which differ in serving size and average alcohol content by volume, in their association with adverse outcomes related to alcohol use. Our results extended the findings of Kponee et al.17 by showing that, among underage drinkers, consumption of premixed- or ready-to-drink cocktails and supersized alcopops had greater adverse effects than did use of non-FAB drinks and flavored malt beverages. In 2010, largely in response to data showing that the coingestion of caffeine and alcohol results in adverse behavioral outcomes, alcohol-related hospitalization, and even death, the US Food and Drug Administration issued a warning to 4 leading manufacturers of these products stating that caffeine added to malt alcohol is an “unsafe food additive.”21 Consequently, the manufacturers of these ready-todrink products removed additives such as caffeine, guarana, and taurine. Even so, supersized alcopops in particular remain largely unregulated and continue to present an emerging public health problem of harmful alcohol consumption among youths. These products come in single-serving cans of 16 ounces or more that resemble typical soft drink containers but have up to 12% alcohol by volume, which can be equivalent to 4.7 standard drinks.22 Supersized alcopops are particularly hazardous because they are sweet tasting and provide youths “with a big bang for their buck.”22 In October 2011, the Federal Trade Commission enforced a change in labeling and packaging of Four Loko cans to specify
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that these drinks contain as much alcohol as 4 to 5 cans of beer and to make the cans resealable.23 According to the commission, the manufacturer, Phusion Projects, had falsely claimed that a 23.5-ounce can of Four Loko contained the same amount of alcohol as 1 or 2 regular 12-ounce beers,23 when in fact the consumption of a single can of Four Loko would by itself constitute an episode of heavy drinking.23
Limitations Our cross-sectional survey data did not allow us to determine a causal relationship between FAB use and risky drinking behavior and adverse alcohol-related outcomes. Although it is possible that consuming FABs caused the higher rate of adverse outcomes observed among these youths, it is also possible that an underlying predisposition to risky behavior actually preceded and caused the FAB use.24,25 Longitudinal research that captured exclusive FAB use versus non---FAB use among youths would be necessary to definitively establish the causal relationship. Another important limitation to our study was the small number of exclusive supersized alcopop users (n = 23), so caution should be used when generalizing results across this particular group. Yet, this category captured a unique subset of FAB users, and our findings can be used as a valuable benchmark for future research identifying differences in FAB consumption.
Conclusions We found that the consumption of premixed- or ready-to-drink cocktails, supersized alcopops, and a combination of FABs was associated with adverse outcomes. This means that, even with caffeine and other stimulants removed, the reformulated alcopops still represent a significant public health threat. Our results also highlight the serious problem posed by premixed- or ready-to-drink cocktails. Use of these sweet-tasting, soft drink--like alcohol products is associated with increased drinking, episodic heavy drinking, fighting, and alcohol-related injury among underage drinkers. Public health practitioners and policymakers need to evaluate and consider regulatory actions for FABs, including marketing and packaging restrictions. j
About the Authors Alison Burke Albers, Michael Siegel, and William DeJong are with the Department of Community Health Sciences, Boston University School of Public Health, Boston, MA. Rebecca L. Ramirez and David H. Jernigan are with the Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Craig Ross is with Fiorente Media Inc, Natick, MA. Correspondence should be sent to Alison Albers, Assistant Professor, Dept of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Ave, 3rd Floor, Boston, MA 02118 (e-mail: aalbers@bu. edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted September 20, 2014.
Contributors A. B. Albers researched the literature, performed all of the statistical analyses, and drafted the initial article. M. Siegel, C. Ross, and D. H. Jernigan oversaw the statistical analyses. All authors interpreted the findings, read and commented on the drafts, and approved the final version of the article.
Acknowledgments This work was supported by the National Institute on Alcohol Abuse and Alcoholism (R01 AA020309-01).
Human Participant Protection The institutional review board of the Boston University Medical Center approved this study.
References 1. Alcohol-Related Disease Impact (ARDI). Atlanta, GA: Centers for Disease Control and Prevention; 2014.
10. Stevenson RJ, Copeland J, Gates P. The role of experience in liking ’ready-to-drink’ alcoholic beverages. Psychol Addict Behav. 2007;21(4):564---569. 11. Metzner C, Kraus L. The impact of alcopops on adolescent drinking: a literature review. Alcohol Alcohol. 2008;43(2):230---239. 12. Mosher JF. Joe Camel in a bottle: Diageo, the Smirnoff brand, and the transformation of the youth alcohol market. Am J Public Health. 2012;102(1):56---63. 13. KnowledgePanel. Design Summary. Menlo Park, CA: Knowledge Networks; 2013. Available at: http://www. knowledgenetworks.com/knpanel/docs/KnowledgePanel %28R%29-Design-Summary-Description.pdf. Accessed January 16, 2013. 14. Cleary K, Levine DA, Hoffman RS. Adolescents and young adults presenting to the emergency department intoxicated from a caffeinated alcoholic beverage: a case series. Ann Emerg Med. 2012;59(1):67---69. 15. Siegel M, DeJong W, Naimi TS, et al. Brand-specific consumption of alcohol among underage youth in the United States. Alcohol Clin Exp Res. 2013;37(7):1195---1203. 16. DiSogra C. Overview of Knowledge Panel Statistical Weighting Protocol. Menlo Park, CA: Knowledge Networks; 2009. Available at: http://www.knowledgenetworks.com/ ganp/docs/KN-Weighting-Synopsis.pdf. Accessed October 11, 2012. 17. Kponee KZ, Siegel M, Jernigan DH. The use of caffeinated alcoholic beverages among underage drinkers: results of a national survey. Addict Behav. 2014;39(1):253---258. 18. Brache K, Stockwell T. Drinking patterns and risk behaviors associated with combined alcohol and energy drink consumption in college drinkers. Addict Behav. 2011;36(12):1133---1140.
2. Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings. Ann Arbor, MI: Institute for Social Research, University of Michigan; 2011.
19. Marczinski CA. Alcohol mixed with energy drinks: consumption patterns and motivations for use in U.S. college students. Int J Environ Res Public Health. 2011; 8(8):3232---3245.
3. Center for Behavioral Health Statistics and Quality. The DAWN Report: Highlights of the 2010 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2012.
20. O’Brien MC, McCoy TP, Rodes SD, Wagone A, Wolfson M. Caffeinated cocktails: energy drink consumption, high-risk drinking, and alcohol-related consequences among college students. Acad Emerg Med. 2008;15(5):453---460.
4. Fortunato EK, Siegel M, Ramirez RL, et al. Brandspecific consumption of flavored alcoholic beverages among underage youth in the United States. Am J Drug Alcohol Abuse. 2014;40(1):51---57. 5. Rossheim ME, Thombs DL. Multiple fruit-flavored alcoholic drinks in a can (MFAC): an overlooked class of potentially harmful alcohol products. Am J Drug Alcohol Abuse. 2013;39(5):280---283. 6. Copeland J, Stevenson RJ, Gates P, Dillon P. Young Australians and alcohol: the acceptability of ready-todrink (RTD) alcoholic beverages among 12---30-yearolds. Addiction. 2007;102(11):1740---1746. 7. Hughes K, MacKintosh AM, Hastings G, Wheeler C, Watson J, Inglis J. Young people, alcohol, and designer drinks: quantitative and qualitative study. BMJ. 1997;314(7078):414---418. 8. Mosher JF, Johnsson D. Flavored alcoholic beverages: an international marketing campaign that targets youth. J Public Health Policy. 2005;26(3):326---342. 9. Romanus G. Alcopops in Sweden—a supply side initiative. Addiction. 2000;95(12, suppl 4):609---619.
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21. US Food and Drug Administration. Caffeinated alcoholic beverages. 2010. Available at: http://www .fda.gov/Food/IngredientsPackagingLabeling/ FoodAdditivesIngredients/ucm190366.htm. Accessed February 14, 2014. 22. Vimont C. Alcohol watchdogs target supersized alcopops as urgent issue. 2011. Available at: http://www. drugfree.org/join-together/alcohol/alcohol-watchdogstarget-supersized-alcopops-as-urgent-issue. Accessed January 21, 2014. 23. Federal Trade Commission. FTC requires packaging changes for fruit-flavored four loko malt beverage. 2011. Available at: http://www.ftc.gov/news-events/pressreleases/2011/10/ftc-requires-packaging-changes-fruitflavored-four-loko-malt. Accessed February 14, 2014. 24. Howland J, Rohsenow JD, Arnedt T, et al. The acute effects of caffeinated versus non-caffeinated alcoholic beverage on driving performance and attention/reaction time. Addiction. 2011;106(2):335---341. 25. Howland J, Rohsenow DJ. Risks of energy drinks mixed with alcohol. JAMA. 2013;309(3)245---246.
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Flavored Alcoholic Beverage Use, Risky Drinking Behaviors, and Adverse Outcomes Among Underage Drinkers: Results From the ABRAND Study Alison Burke Albers, PhD, Michael Siegel, MD, MPH, Rebecca L. Ramirez, MPH, Craig Ross, PhD, MBA, William DeJong, PhD, and David H. Jernigan, PhD
Alcohol continues to be the most commonly used drug among youths in the United States and is responsible for more than 4300 annual deaths among underage drinkers.1 Approximately 33% of eighth graders and 70% of 12th graders have consumed alcohol, and 13% of eighth graders and 40% of 12th graders drank during the past month.2 Close to 200 000 emergency department visits by persons younger than 21 years are reported annually for injuries and other conditions linked to alcohol.3 An important trend in underage drinking is the popularity of flavored alcoholic beverages (FABs).4---12 Despite their popularity, little is known about associations between FAB consumption, risky drinking behaviors, and related harms among underage drinkers. FAB brands can be classified into 3 categories: malt-based beverages; spirits-based, premixed- or ready-to-drink cocktails; and supersized alcopops.4 Although these products are widely classified as FABs, distinctions between them are important because these beverages differ in serving size (e.g., the supersized alcopops can contain 2 to 3 times the alcohol volume of other brands) and average alcohol content by volume (malt beverages, 7.8%; premixed- or ready-to-drink cocktails, 14.2%; supersized alcopops, 10.8%).4 We used ABRAND (Alcohol Brand Research among Underage Youth) data collected by GfK Knowledge Networks13 to analyze the brands of alcoholic beverages a national sample of youth drinkers aged 13 to 20 years reported consuming and found that nearly half of young drinkers (n = 515) had consumed FABs in the past 30 days.4 These results roughly matched those of the 2012 Monitoring the Future report, which found that more than half (57.5%) of students in grades 8, 10, and 12 who reported past 30-day alcohol use had consumed at least 1 FAB during that time.2 The ABRAND data also
Objectives. We examined associations between consumption of different types of flavored alcoholic beverages (FABs) and risky drinking and drinkingrelated harms among underage drinkers. Methods. For the Alcohol Brand Research among Underage Youth study, we applied multivariable logistic regression analyses to data from underage drinkers (n = 1031, aged 13–20 years), recruited from a national Internet panel in 2011 to 2012, to estimate associations between consumption of malt-based drinks; spirits-based, premixed- or ready-to-drink cocktails; and supersized alcopops, alone or in combination, and alcohol-related outcomes. Results. After adjustment for confounding variables, the exclusive consumption of alcopops was associated with episodic heavy drinking (odds ratio [OR] = 4.35; 95% confidence interval [CI] = 1.24, 15.31; P < .05) and alcohol-related injuries (OR = 6.25; 95% CI = 1.34, 29.10; P < .05). Exclusive consumption of cocktails was associated with episodic heavy drinking (odds ratio [OR] = 2.61; 95% CI = 1.26, 5.41; P < .05) and injuries requiring medical attention (OR = 6.50; 95% CI = 2.09, 20.17; P < .001. Exclusive consumption of 2 or more FABs was associated with episodic heavy drinking (OR = 2.78; 95% CI = 1.25, 6.16; P < .05), fighting (OR = 3.30; 95% CI = 1.46, 7.47; P < .001), and alcohol-related injuries (OR = 2.83; 95% CI = 1.43, 5.58; P < .001). Conclusions. FABs present an emerging public health problem among youths. (Am J Public Health. 2015;105:810–815. doi:10.2105/AJPH.2014.302349)
showed that 43% of drinkers aged 13 to 15 years, 48.9% of those aged 16 to 18 years, and 52% of those aged 19 to 20 years consumed FABs.4 Consumption prevalence was greatest for malt beverages (33.8%), followed by premixed- or ready-to-drink cocktails (23.9%) and supersized alcopops (8.6%). Almost one quarter of respondents (24.5%) had consumed at least 1 FAB during a heavy-drinking episode (defined as consuming ‡ 5 drinks in a row).4 FABs’ high alcohol content, low price, sweet flavoring, attractive packaging, and targeted marketing strategies have caused concern that FAB consumption might disproportionately contribute to alcohol-related emergency department visits by underage drinkers.5 One case study found that consumption of supersized alcopops such as Four Loko contributed to alcohol-related emergencies involving drinkers as young as 13 years.14
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We used the ABRAND sample of underage drinkers to examine the relationship between consumption of different types and combinations of FABs and risky drinking behaviors and adverse outcomes among youths aged 13 to 20 years.
METHODS Here we provide a brief overview of the study sample and data collection procedures; complete details have been published elsewhere.15 In December 2011 through May 2012, we used a prerecruited, randomly selected Internet panel maintained by GfK Knowledge Networks of Palo Alto, California,13 to obtain a sample of 1031 youths aged 13 to 20 years who had consumed at least 1 alcoholic drink during the past 30 days. We conducted an online, self-administered survey to learn what brands of alcohol respondents had
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consumed during the past 30 days, the number of days on which they consumed each brand, and the typical number of drinks of each brand they consumed on those days.
Sample Knowledge Networks used its established national Internet panel to recruit adolescents aged 13 to 17 years and young adults aged 18 to 20 years via e-mail to participate in our Internet survey. To identify respondents aged 13 to 17 years, the network asked adult panelists whether they had children in that age range who could be invited, with parental permission, to participate in a survey. The network randomly selected 1 youth from each household. If parental consent was given, Knowledge Networks e-mailed the youth an invitation to participate in the survey. The sample of respondents aged 13 to 17 years was representative of the households in the national Internet panel. Panelists aged 18 to 20 years received an e-mail invitation from Knowledge Networks that did not indicate that the survey concerned alcohol consumption. Panelists who agreed to participate in the survey received an e-mail message containing a link to a secure Web site, which presented a screening questionnaire that determined whether the panelist consumed alcohol in the past 30 days and was thus eligible for the survey. All participants who completed the online consent form and survey received a $25 gift credited to their panel account. The response rates were 43.4% for panelists aged 18 to 20 years and 44.4% for those aged 13 to 17 years. We dropped a single respondent who reported drinking more than 15 drinks per day and more than 20 different alcohol brands. This resulted in a final sample of 1031 individuals: 41.5% were male; 11.4% were aged 13 to 15 years; 44.7% were aged 16 to 18 years; 43.9% were aged 19 to 20 years; 57.4% were White, non-Hispanic; 20.8% were Hispanic; 12.2% were Black; and 9.6% were other. Frequency of alcohol consumption in the past 30 days was 1 day (28.6%), 2 to 3 days (29.9%), 4 to 7 days (20.1%), and 8 or more days (21.4%). Approximately half the sample (49.7%) reported episodic heavy drinking (consuming ‡ 5 drinks in a row) in the past 30 days.
To assess possible nonresponse bias, we compared 18- to 20-year-old respondents and nonrespondents on basic demographic factors; we used the v2 test to assess the significance of observed differences. Nonrespondents were slightly older (P < .05), but similar in gender (P = .41), and were more likely to be Black (P < .001), to come from lower-income households (P < .01), and to have lacked Internet access prior to enrolling with Knowledge Networks (P < .001). We observed no significant differences by region (P = .11).
Survey Instrument and Measures The survey determined brand-specific alcohol consumption among underage drinkers for 898 major brands of alcohol, including 62 FABs. Our previously published study identified the types of beverages considered to be FABs: (1) malt-based flavored beverages (e.g., Bacardi malt beverages; n = 10); (2) spirits-based, premixed- or ready-to-drink cocktails (e.g., Jack Daniel’s cocktails; n = 44); and (3) supersized alcopops, which are sold in 16-ounce or larger containers and have at least 10% alcohol by volume (e.g., Four Loko; n = 8).4 These distinctions are important because, although all of these brands are classified as FABs, they differ in serving size and average alcohol content by volume.4 None of the FABs we analyzed contained caffeine. The complete list of all brands classified under these 3 categories has been published elsewhere.4 We used the National Institute on Alcohol Abuse and Alcoholism’s definition of a standard drink, which contains 14 grams of pure alcohol,15 and the average alcohol content of the 62 FAB brands to define 1 FAB standard drink as 8.5 ounces. To help respondents accurately report the number of standard drinks they consumed, the survey provided a visual aid with pictures of various types of alcoholic beverages and the number of ounces per standard drink for each type (a 12-ounce can of beer, an 8.5-ounce bottle of a FAB, a 1.5ounce shot of liquor, and a 5-ounce glass of wine). This picture was available on each page of the survey, and instructions reminded respondents of the volume size representing 1 standard drink as they answered questions about each type of alcoholic beverage. Beverages and risky behaviors. We determined prevalence estimates for 4 mutually
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exclusive FAB user categories: (1) FAB consumers who drank malt beverages exclusively (n = 176), (2) FAB consumers who drank premixed- or ready-to-drink cocktails exclusively (n = 102), (3) FAB consumers who drank supersized alcopops exclusively (n = 23), and (4) FAB consumers who used any combination of 2 or more FAB categories exclusively (n = 198). We compared each of these groups to participants who did not consume any FABs (n = 532). We assessed 4 primary outcome measures related to risky drinking behaviors: (1) the average number of drinking days per month, (2) the average number of drinks per day, (3) the average total number of drinks per month, and (4) episodic heavy drinking, defined as consuming 5 or more drinks in a row. Adverse outcomes related to drinking. We examined 3 primary adverse outcomes in the past 12 months: (1) fighting during or after drinking, (2) sustaining an alcohol-related injury, and (3) having an alcohol-related injury seen by a medical professional. Specifically, respondents were asked, “During the past 12 months, how often did you get into a physical fight while or after drinking?” We used responses to this question to create a dichotomous indicator of any fighting versus no fighting during the past 12 months. Respondents were also asked, “During the past 12 months, how often did you have an injury where any part of your body was hurt while or after drinking?” We used responses to this question to create a dichotomous indicator of any injury versus no injury. The respondents who reported an injury were next asked, “Of the times when you were injured, how many of those times was the injury serious enough that a medical professional was consulted?” From this question, we created a dichotomous indicator of any injury requiring a medical consultation versus no injury. Control variables. We differentiated youths by age: (1) 13 to 15 years, (2) 16 to 18 years, and (3) 19 to 20 years. We categorized race/ ethnicity into 4 groups: Hispanic; Black, nonHispanic; White, non-Hispanic; and other, with White, non-Hispanic as the reference group. We categorized reported household income into 4 groups: (1) less than $15 000, (2) $15 001 to $39 999, (3) $40 000 to $99 000, and (4) $100 000 or more. We also controlled for gender.
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Respondents were also asked, “During the past 30 days, on how many days did you smoke cigarettes?” We created a dichotomous variable of any smoking versus no smoking at all during the past 30 days. Our models also included seat belt use as a covariate because it has been shown to be a strong correlate of general risk taking among youths. Respondents were asked, “How often do you wear a seat belt when you are riding in or driving a car?” We created a dichotomous indicator of always wearing a seat belt versus all other seat belt use. Our models also included the total number of drinks consumed per month.
Statistical Analyses To render the sample representative of the underlying population of youths aged 13 to 20 years, Knowledge Networks applied statistical weighting adjustments to account for selection deviations.16 These weights accounted for the different selection probabilities associated with the company’s random-digit-dialing and address-based sampling procedures, oversampling of minority communities, nonresponse to panel recruitment, and panel attrition. The poststratification weights adjusted for gender, age, race/ethnicity, census region, household income, home ownership status, metropolitan area, and household size, derived from demographic distributions from the Current Population Survey, conducted by the US Census Bureau.13,16 We conducted multiple logistic regression analyses for each of the 4 binary outcome variables—episodic heavy drinking, fighting, alcohol-related injury, and injury requiring medical attention—with adjustment for potential differences in population characteristics across the beverage categories: age, gender, race/ethnicity, income, smoking status, total number of drinks consumed per month, and general risk taking (seat belt use). These analyses examined the independent effect of drinking each type of FAB: (1) malt beverages exclusively, (2) premixed- or ready-to-drink cocktails exclusively, (3) supersized alcopops exclusively, and (4) exclusive use of any combination of 2 or more FAB categories. We used Stata SE version 12.1 (StataCorp LP, College Station, TX) for all analyses.
RESULTS The Venn diagram in Figure 1 illustrates the entire distribution of specific FAB usage among our young respondents. This shows that 176 youths reported drinking only malt beverages, 102 reported drinking only premixed- or ready-to-drink cocktails, and 23 reported only drinking supersized alcopops. In addition, 122 participants reported drinking both malt beverages and premixed- or ready-to-drink cocktails, 19 reported drinking both malt beverages and alcopops, and 19 reported drinking both premixed- or ready-to-drink cocktails and alcopops. An additional 38 youths reported drinking all 3 FAB types. In total, 198 youths reported drinking any combination of 2 or more FAB categories. As shown in Table 1, youths who reported exclusive alcopop use in the past 30 days drank significantly more days per month (mean = 9.1) than did exclusive malt beverage users (mean = 4.7), exclusive premixed- or ready-todrink cocktail users (mean = 4.8), and non--FAB users (mean = 4.7). Youths who reported exclusive use of any combination of 2 or more
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FAB categories in the past 30 days also drank on significantly more days per month (mean = 7.8) than did malt beverage users, premixed- or ready-to-drink cocktail users, and non---FAB users. We found no statistically significant differences in the average number of drinks per day among exclusive premixed- or ready-to-drink cocktail users (mean = 3.8), exclusive alcopop users (mean = 4.7), and combination FAB users (mean = 4.0). Users from these 3 groups reported significantly more drinks per day than did exclusive malt beverage users (mean = 2.9) and non---FAB users (mean = 3.1). The average total number of drinks in the past month was significantly higher among exclusive supersized alcopop users than among other categories of users (mean = 52.6 drinks for alcopop users, 35.2 for combination FAB users, 25.8 for exclusive premixed- or ready-to-drink cocktail users, 15.9 for exclusive malt beverage users, and 17.7 for non---FAB users). Youths who exclusively used premixed- or ready-to-drink cocktails or were combination FAB users also had a significantly higher average total numbers of drinks per month than did malt beverage users and non---FAB users.
Flavored malt beverage user only n = 176 n = 122
n = 19 n = 38
Premixed- or ready-to-drink cocktail user only n = 102
n = 19
Supersized alcopops user only n = 23
Note. This Venn diagram demonstrates the interaction of the use of flavored malt; spirits-based, premixed- or ready-to-drink cocktails; and supersized alcopops. FABs are defined as brands belonging to 1 of these 3 categories of alcoholic beverages. Supersized alcopops are sold in 16-ounce-or-greater containers and contain at least 10% alcohol by volume. The sample size of any combination of 2 or more FAB categories is n = 198.
FIGURE 1—Venn diagram of flavored alcoholic beverage (FAB) brand use among underage drinkers.
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TABLE 1—Prevalence of Risky Drinking Behavior Among Underage Exclusive Users of Different Types of Flavored Alcoholic Beverages (FABs): ABRAND Study, United States, 2011–2012 User Type
Drinking Days per Month, Mean (95% CI)
Drinks per Day, Mean (95% CI)
Total Drinks per Month, Mean (95% CI)
Episodic Heavy Drinkers, % (95% CI)
Non-FAB (n = 532)
4.7 (4.3, 5.2)
3.1 (2.8, 3.3)
17.7 (15.0, 20.4)
44.8 (40.5, 48.9)
Exclusively flavored malt beverages (n = 176)
4.7 (4.1, 5.4)
2.9 (2.5, 3.2)
15.9 (12.4, 19.4)
45.1 (37.7, 52.5)
Exclusively premixed- or ready-to-drink cocktails (n = 102) Exclusively supersized alcopops (n = 23)
4.8 (4.0, 5.6) 9.1 (5.5, 12.8)
3.8 (3.1, 4.5) 4.7 (2.9, 6.6)
25.8 (18.1, 33.6) 52.6 (30.3, 74.9)
69.6 (60.5, 78.6) 76.5 (57.8, 95.3)
Combination of FABs (n = 198)
7.8 (6.9, 8.8)
4.0 (3.6, 4.5)
35.2 (29.2, 41.2)
79.5 (73.4, 85.1)
Note. ABRAND = Alcohol Brand Research among Underage Youth; CI = confidence interval. FABs were categorized as (1) flavored malt beverages (n = 10); (2) spirits-based, premixed- or ready-todrink cocktails (n = 44); or (3) supersized alcopops, sold in 16-ounce-or-greater containers and containing at least 10% alcohol by volume (n = 8). Combination FAB users reported exclusive consumption of 2 or more FAB types.
Exclusive premixed- or ready-to-drink cocktail use, exclusive supersized alcopop use, and combination FAB use were significantly associated with episodic heavy drinking. Nearly 70% of premixed- or ready-to-drink cocktail users, about three quarters (76.5%) of alcopop users, and almost 80% of combination FAB users were episodic heavy drinkers, far more than the 45.1% of malt beverage users and 44.8% of non---FAB users who reported engaging in heavy-drinking episodes. Youths who exclusively consumed premixedor ready-to-drink cocktails or supersized alcopops and combination FAB drinkers had a higher proportion of adverse outcomes than did youths who consumed malt beverages exclusively or did not consume FABs at all (Table 2). Fighting was significantly more prevalent among premixed- or ready-to-drink cocktail users (22.8%), than among alcopop users (18.6%), malt beverage users (3.7%), and non---FAB users (8.6%). Drinking a combination of FABs was also significantly associated
with fighting (21.3%). Alcopop users were significantly more likely to report fighting than were malt beverage users but not non---FAB users. Slightly more than 50% of exclusive supersized alcopop users and 42.1% of combination FAB users reported alcohol-related injuries; 24.3% of exclusive premixed- or ready-todrink cocktail users, 14.1% of exclusive malt beverage users, and 14.4% of non---FAB users reported such injuries. A significantly higher proportion of premixed- or ready-to-drink cocktail users and combination FAB users had an alcohol-related injury requiring a doctor visit than did users of the other beverage categories: injuries sent 13.8% of premixedor ready-to-drink cocktail users, 8.2% of combination FAB users, 6.8% of alcopop users, and 1.3% of both malt beverage users and non---FAB users to the doctor. Table 3 shows the results from logistic regression models that examined the association between exclusive FAB use and adverse outcomes related to drinking, after adjustment
for age, gender, race/ethnicity, income, smoking status, total number of drinks consumed in the past month, and seat belt use. Use of premixed- or ready-to-drink cocktails, supersized alcopops, and any combination of 2 or more FABs was significantly associated with episodic heavy drinking. Premixed- or readyto-drink cocktail users were more than twice as likely as non---FAB users to engage in episodic heavy drinking (odds ratio [OR] = 2.61; 95% confidence interval [CI] = 1.24, 5.41; P < .05), and combination FAB users were nearly 3 times as likely as non---FAB users to engage in episodic heavy drinking (OR = 2.78; 95% CI = 1.25, 6.16; P < .05). Supersized alcopop users were more than 4 times as likely as non---FAB users to engage in episodic heavy drinking (OR = 4.35; 95% CI = 1.24, 15.31; P < .05). In the multivariable logistic model, only combination FAB use was associated with fighting: combination users were more than 3 times as likely as non---FAB users to
TABLE 2—Prevalence of Adverse Drinking-Related Outcomes Among Underage Exclusive Users of Different Types of Flavored Alcoholic Beverages (FABs): ABRAND Study, United States, 2011–2012 Fighting, % (95% CI)
Alcohol-Related Injury, % (95% CI)
Injury Requiring Doctor Visit, % (95% CI)
8.6 (6.1, 10.9) 3.7 (0.8, 6.5)
14.4 (11.2, 17.3) 14.1 (8.7, 19.4)
1.3 (0.3, 2.2) 1.3 (0.0, 3.0)
Exclusively premixed- or ready-to-drink cocktails (n = 102)
22.8 (14.3, 31.3)
24.3 (15.6, 33.0)
13.8 (6.8, 20.8)
Exclusively supersized alcopops (n = 23)
18.6 (1.4, 35.7)
50.7 (27.9, 73.4)
6.8 (0.0, 17.9)
Combination of FABs (n = 198)
21.3 (15.5, 27.1)
42.1 (34.9, 49.1)
8.2 (4.3, 12.0)
User Type Non-FAB (n = 532) Exclusively flavored malt beverages (n = 176)
Note. ABRAND = Alcohol Brand Research among Underage Youth; CI = confidence interval. FABs were categorized as (1) flavored malt beverages (n = 10); (2) spirits-based, premixed- or ready-todrink cocktails (n = 44); or (3) supersized alcopops, sold in 16-ounce-or–greater containers and containing at least 10% alcohol by volume (n = 8). Combination FAB users reported exclusive consumption of 2 or more FAB types.
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TABLE 3—Multivariable Logistic Regression of Flavored Alcoholic Beverage (FAB) Use Among Underage Drinkers: ABRAND Study, United States, 2011–2012 User Type
Episodic Heavy Drinking, AOR (95% CI)
Fighting, AOR (95% CI)
Alcohol-Related Injury, AOR (95% CI)
Injury Requiring Doctor Visit, AOR (95% CI)
Non-FAB (Ref; n = 532)
1.00
1.00
1.00
1.00
Exclusively flavored malt beverages (n = 176)
0.96 (0.49, 1.89)
0.42 (0.11, 1.69)
0.83 (0.32, 2.13)
0.42 (0.04, 4.69)
Exclusively premixed- or ready-to-drink cocktails (n = 102) Exclusively supersized alcopops (n = 23)
2.61* (1.26, 5.41) 4.35* (1.24, 15.31)
1.45 (0.40, 5.30) 0.76 (0.14, 4.09)
2.55 (0.91, 7.18) 6.25* (1.34, 29.10)
6.50** (2.09, 20.17) 1.86 (0.22, 15.66)
Combination of FABs (n = 198)
2.78* (1.25, 6.16)
3.30** (1.46, 7.47)
2.83** (1.43, 5.58)
2.90 (0.87, 9.68)
Note. ABRAND = Alcohol Brand Research among Underage Youth; AOR = adjusted odds ratio; CI = confidence interval. FABs were categorized as (1) flavored malt beverages (n = 10); (2) spiritsbased, premixed- or ready-to-drink cocktails (n = 44); or (3) supersized alcopops, sold in 16-ounce-or-greater containers and containing at least 10% alcohol by volume (n = 8). Combination FAB users reported exclusive consumption of 2 or more FAB types. Odds ratios adjusted for age, gender, race/ethnicity, income, smoking status, total number of drinks per month, and seat belt use. *P < .05; **P < .001.
engage in fighting (OR = 3.30; 95% CI = 1.46, 7.47; P < .001). Both exclusive alcopop use and combination FAB use were associated with alcohol-related injury (Table 3). Alcopop users were more than 6 times as likely as non---FAB users to report an alcohol-related injury (OR = 6.25; 95% CI = 1.34, 29.10; P < .05), and combination FAB users were nearly 3 times as likely as non---FAB users to report an alcohol-related injury (OR = 2.83; 95% CI = 1.43, 5.58; P < .001). Premixed- or ready-to-drink cocktail users were nearly 7 times as likely as non---FAB users to report an injury requiring a doctor visit (OR = 6.50; 95% CI = 2.09, 20.17; P < .001). We detected no statistically significant relationship between alcopop use or combination FAB use and reporting an alcohol-related injury requiring a doctor visit.
DISCUSSION We found that underage drinkers who reported 3 types of exclusive FAB use—premixedor ready-to-drink cocktails only, supersized alcopops only, and any combination of 2 or more FABs—consumed, on average, more drinks per day; drank on more days per month; and were likelier to engage in episodic heavy drinking. These results were particularly striking among alcopop users, who consumed double the total number of drinks per month consumed by users of premixed- or ready-to-drink cocktails and triple the total number of drinks consumed by malt beverage users and non--FAB users. A remarkable 69.6% of premixedor ready-to-drink cocktail users, 76.5% of
alcopop users, and 79.5% of combination FAB users reported episodic heavy drinking; only approximately 40% of malt beverage users and non---FAB users reported binge drinking. Alcopop users were 4 times as likely as non--FAB users to drink at this level, after adjustment for a host of variables. Both users of premixedor ready-to-drink cocktails and combination FAB users were nearly 3 times as likely as non---FAB users to report episodic heavy drinking. Supersized alcopop and combination FAB users were also significantly more likely than non---FAB users to sustain alcohol-related injuries; alcopop users’ odds were fully 6 times as high as for the referent group, underage drinkers who did not consume FABs. Combination FAB users were significantly more likely than non---FAB users to engage in fighting. Premixed- or ready-to-drink cocktail users were more than than 6 times as likely as non--FAB users to sustain an alcohol-related injury serious enough to require a medical professional consultation. Our findings were similar to those of other research indicating that mixing energy drinks with alcohol is associated with greater risk for both adverse outcomes of drinking and increased risk-taking behaviors.17---20 The most recent study found that adolescents who consumed caffeinated alcoholic beverages, particularly premixed caffeinated alcoholic beverages or self-mixed alcoholic beverages with energy drinks or energy shots, were at an increased risk of adverse outcomes, including episodic heavy drinking, fighting, and alcoholrelated injury.17
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To the best of our knowledge, ours was the first study to examine distinctions among the 3 major types of FAB products, which differ in serving size and average alcohol content by volume, in their association with adverse outcomes related to alcohol use. Our results extended the findings of Kponee et al.17 by showing that, among underage drinkers, consumption of premixed- or ready-to-drink cocktails and supersized alcopops had greater adverse effects than did use of non-FAB drinks and flavored malt beverages. In 2010, largely in response to data showing that the coingestion of caffeine and alcohol results in adverse behavioral outcomes, alcohol-related hospitalization, and even death, the US Food and Drug Administration issued a warning to 4 leading manufacturers of these products stating that caffeine added to malt alcohol is an “unsafe food additive.”21 Consequently, the manufacturers of these ready-todrink products removed additives such as caffeine, guarana, and taurine. Even so, supersized alcopops in particular remain largely unregulated and continue to present an emerging public health problem of harmful alcohol consumption among youths. These products come in single-serving cans of 16 ounces or more that resemble typical soft drink containers but have up to 12% alcohol by volume, which can be equivalent to 4.7 standard drinks.22 Supersized alcopops are particularly hazardous because they are sweet tasting and provide youths “with a big bang for their buck.”22 In October 2011, the Federal Trade Commission enforced a change in labeling and packaging of Four Loko cans to specify
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that these drinks contain as much alcohol as 4 to 5 cans of beer and to make the cans resealable.23 According to the commission, the manufacturer, Phusion Projects, had falsely claimed that a 23.5-ounce can of Four Loko contained the same amount of alcohol as 1 or 2 regular 12-ounce beers,23 when in fact the consumption of a single can of Four Loko would by itself constitute an episode of heavy drinking.23
Limitations Our cross-sectional survey data did not allow us to determine a causal relationship between FAB use and risky drinking behavior and adverse alcohol-related outcomes. Although it is possible that consuming FABs caused the higher rate of adverse outcomes observed among these youths, it is also possible that an underlying predisposition to risky behavior actually preceded and caused the FAB use.24,25 Longitudinal research that captured exclusive FAB use versus non---FAB use among youths would be necessary to definitively establish the causal relationship. Another important limitation to our study was the small number of exclusive supersized alcopop users (n = 23), so caution should be used when generalizing results across this particular group. Yet, this category captured a unique subset of FAB users, and our findings can be used as a valuable benchmark for future research identifying differences in FAB consumption.
Conclusions We found that the consumption of premixed- or ready-to-drink cocktails, supersized alcopops, and a combination of FABs was associated with adverse outcomes. This means that, even with caffeine and other stimulants removed, the reformulated alcopops still represent a significant public health threat. Our results also highlight the serious problem posed by premixed- or ready-to-drink cocktails. Use of these sweet-tasting, soft drink--like alcohol products is associated with increased drinking, episodic heavy drinking, fighting, and alcohol-related injury among underage drinkers. Public health practitioners and policymakers need to evaluate and consider regulatory actions for FABs, including marketing and packaging restrictions. j
About the Authors Alison Burke Albers, Michael Siegel, and William DeJong are with the Department of Community Health Sciences, Boston University School of Public Health, Boston, MA. Rebecca L. Ramirez and David H. Jernigan are with the Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD. Craig Ross is with Fiorente Media Inc, Natick, MA. Correspondence should be sent to Alison Albers, Assistant Professor, Dept of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Ave, 3rd Floor, Boston, MA 02118 (e-mail: aalbers@bu. edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted September 20, 2014.
Contributors A. B. Albers researched the literature, performed all of the statistical analyses, and drafted the initial article. M. Siegel, C. Ross, and D. H. Jernigan oversaw the statistical analyses. All authors interpreted the findings, read and commented on the drafts, and approved the final version of the article.
Acknowledgments This work was supported by the National Institute on Alcohol Abuse and Alcoholism (R01 AA020309-01).
Human Participant Protection The institutional review board of the Boston University Medical Center approved this study.
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