Binge Drinking and Energy Drinks

Some consumers want low levels of caffeine for health reasons, and others prefer the effects of higher caffeine, said food scientist Leonard Bell. The addition of caffeine contents to food labels would help them make better choices.

In their study, published in the August issue of the Journal of Food Science, Bell and fellow researcher Ken-Hong Chou described their evaluation of 56 national brands and 75 store brands of carbonated beverages.

According to the study, the U.S. Food and Drug Administration sets the legal limit of caffeine in carbonated beverages at about 72 milligrans of caffeine for a 12-ounce can of soft drink.

Bell and Chou found the range of caffeine in 12-ounce cans of carbonated beverages to vary from a low of just under 5 milligrans for a store brand of cola to a high of 74 milligrams for Vault Zero, a citrus drink. Their study included cola, pepper-type and citrus beverages of both national-brands and private-label store-brands.

New flavors, formulas and brands of carbonated beverages are continually being introduced into the market, but since most do not provide caffeine content information in their labeling, consumers cannot make quick choices based on comparison at the point of purchase.

In their article, Bell and Chou conclude that if all manufacturers placed caffeine contents on food labels, consumers would have the ability to instantly compare products, enabling them to make more informed purchasing decisions.

Earlier this month Monster Beverage reported in a Securities and Exchange Commission filing that it was being investigated by an unnamed state attorney general. News reports this week put a name with the story. 

Published reports say New York Attorney General Eric Schneiderman has issued subpoenas to Monster, as well as Living Essentials, maker of the heavily advertised 5-Hour Energy Drink. Scheiderman's office refused to comment on the reports, as did the companies named.

Back in July, Living Essentials said it had received an inquiry from an attorney general, which it did not identify, requesting documents that related to the marketing of its products. According to the reports this week, Schneiderman is investigating whether the companies are overstating claims about the benefits of their products while soft-peddling the role of caffeine.

Health concerns

To date, it has mostly been health officials that have shown concern about energy drinks, which make up a rapidly growing component of the beverage market, mainly because they appeal to young consumers. They're marketed as a quick and easy way to boost energy levels and as an alternative to coffee.

In 2011 researchers at the University of Maryland School of Public Health and Wake Forest University School of Medicine issued a study suggesting highly-caffeinated energy drinks may pose a significant threat to individual and public health.

Writing in the Journal of the American Medical Association (JAMA), they recommended immediate consumer action, education by health providers, voluntary disclosures by manufacturers and new federal labeling requirements.

The study followed a crackdown on energy drinks containing alcohol. A number of states banned those products and, under increasing pressure, Anheuser-Busch ended sales of energy drink products containing alcohol.

Removing alcohol not enough?

“Recent action to make pre-mixed alcoholic energy drinks unavailable was an important first step, but more continued action is needed,” University of Maryland School of Public Health researcher Amelia Arria as the time of the study. “Individuals can still mix these highly caffeinated energy drinks with alcohol on their own. It is also concerning that no regulation exists with regard to the level of caffeine that can be in an energy drink.”

Arria, who also directs the Center on Young Adult Health and Development, and co-author Mary Claire O’Brien, associate professor of emergency medicine at Wake Forest University School of Medicine, alerted various state attorneys general to the risks of alcoholic energy drinks starting in 2009.

Partly as a result of that campaign, the U.S. Food and Drug Administration and Federal Trade Commission too action against some energy drinks with alcohol content.

The 2011 JAMA paper said energy drinks -- even those without alcohol -- have become part of the subculture of partying.

“The practice of mixing energy drinks with alcohol -- which is more widespread than generally recognized -- has been linked consistently to drinking high volumes of alcohol per drinking session and subsequent serious alcohol-related consequences such as sexual assault and driving while intoxicated… Research has demonstrated that individuals who combine energy drinks with alcohol underestimate their true level of impairment,” the authors wrote.

Alcohol marketers have lately adopted the slogan “drink responsibly,” which is a little vague but is generally assumed to mean to drink in moderation.

The long history of alcoholic beverages has revealed the many unfortunate things that can happen when people drink too much. But the problems may be greater than getting into an accident or a fight or damaging your liver.

New research at the University of North Carolina (UNC) shows that heavy alcohol use actually rewires brain circuitry, making it harder for alcoholics to recover psychologically following a traumatic experience.

“There’s a whole spectrum to how people react to a traumatic event,” said study author Thomas Kash, an assistant professor of pharmacology at UNC. “It’s the recovery that we’re looking at -- the ability to say ‘this is not dangerous anymore.’ Basically, our research shows that chronic exposure to alcohol can cause a deficit with regard to how our cognitive brain centers control our emotional brain centers.”

Irrational fear

It's normal to be fearful in a dangerous situation. But once there is no longer any danger, it's normal not to be afraid. When that fear persists, it's often diagnosed as post-traumatic stress disorder (PTSD). The scientists believe alcohol plays a role in that irrational fear.

“A history of heavy alcohol abuse could impair a critical mechanism for recovering from a trauma, and in doing so put people at greater risk for PTSD,” said Andrew Holmes, the study’s senior author. “The next step will be to test whether our pre-clinical findings translate to patients currently suffering from comorbid PTSD and alcohol abuse. If it does, then this could lead to new thinking about how we can better treat these serious medical conditions.”

The North Carolina scientists reached their conclusions based on a study of laboratory mice. Over the course of a month they gave one group of mice doses of alcohol equivalent to double the legal driving limit in humans. A second group of mice was given no alcohol. The team then used mild electric shocks to train all the mice to fear the sound of a brief tone.

When the tone was repeatedly played without the accompanying electric shock, the mice with no alcohol exposure gradually stopped fearing it. The mice with chronic alcohol exposure, on the other hand, froze in place each time the tone was played, even long after the electric shocks had stopped.

Harder to get over the fear

People can react the same way. Patients with PTSD often have trouble overcoming fear even when they are no longer in a dangerous situation.

In the experiment, mice exposed to heavy alcohol concentrations experienced physical changes to their brains. Comparing the brains of the mice, researchers noticed nerve cells in the prefrontal cortex of the alcohol-exposed mice actually had a different shape than those of the other mice.

Holmes said the findings are valuable because they pinpoint exactly where alcohol causes damage that leads to problems overcoming fear.

“We’re not only seeing that alcohol has detrimental effects on a clinically important emotional process, but we’re able to offer some insight into how alcohol might do so by disrupting the functioning of some very specific brain circuits,” he said.

So drinking in moderation, if at all, is important not only to avoid accidents and a damaged liver, but also to avoid physical changes to the brain that can make it much harder to handle a traumatic event.

There's been a big decline in the number of high-schoolers who drink and drive. But, a lot of them are still doing it, too

The percentage of teens in high school (aged 16 and older) who drove when they had been drinking alcohol decreased by 54 percent between 1991 and 2011, according to a Vital Signs study released by the Centers for Disease Control and Prevention. Nine out of 10 say they did not drink and drive during 2011.

“We are moving in the right direction. Rates of teen drinking and driving have been cut in half in 20 years,” said CDC Director Thomas R. Frieden, M.D., M.P.H. “But we must keep up the momentum -- one in 10 high school teens, aged 16 and older, drinks and drives each month, endangering themselves and others.”

For the study, CDC analyzed data from the 1991-2011 national Youth Risk Behavior Surveys (YRBS). These national surveys asked high school students if they had driven a vehicle when they had been drinking alcohol one or more times during the 30 days before the survey; CDC researchers focused their analysis on students aged 16 and older.

Study findings

The study also found that:

• Teens were responsible for approximately 2.4 million episodes of drinking and driving a month in 2011; some engaged in the dangerous behavior more than once a month.
• High school boys ages 18 and older were most likely to drink and drive (18 percent), while 16-year-old high school girls were least likely (6 percent).
• Eighty-five percent of teens in high school who reported drinking and driving in the past month also reported binge drinking. For YRBS, binge drinking means five or more drinks during a short period of time.

“Teens learn from adults,” said Pamela S. Hyde, the Administrator of the Substance Abuse and Mental Health Services Administration. “That is why it is critically important that parents, teachers, coaches and all caring adults in a young person’s life talk with them early and often about the dangers of underage alcohol use as well as drinking and driving.”

Numerous factors

Many efforts have helped reduce teen drinking and driving. Some of the proven, effective strategies include the laws in place in every state that make it illegal to sell alcohol to anyone under age 21 and for those under age 21 to drive after drinking any alcohol, plus the graduated driver licensing systems in every state that allow teens to gain privileges, such as driving at night or driving with passengers, over time.

Parents also have a crucial role to play in keeping their teens safe on the road. They can model safe driving behavior and can consider using tools like parent-teen driving agreements with their teens. Safe driving habits for teens include never drinking and driving, following state GDL laws, and wearing a seat belt on every trip.

The pressure appears to be mounting on Monster Beverage, the maker of Monster energy drinks. The Food and Drug Administration (FDA) says it is looking into any possible link between the high-octane beverage and five deaths. The family of a Maryland teenager who died is suing the company.

The parents of 14-year old Anais Fournier, who died after reportedly consuming two Monster drinks, are suing the company for wrongful death. In a statement the company said it is sure its products had nothing to do with the teen's death.

But energy drinks, in particular those made by Monster, have been under pressure for some time. In late August New York Attorney General Eric Schneiderman was reported to be investigating the health effects of Monster's energy drinks.

Health concerns

Health officials have also been drawing a bead on energy drinks. In 2011 researchers at the University of Maryland School of Public Health and Wake Forest University School of Medicine issued a study suggesting highly-caffeinated energy drinks may pose a significant threat to individual and public health.

Writing in the Journal of the American Medical Association (JAMA), they recommended immediate consumer action, education by health providers, voluntary disclosures by manufacturers and new federal labeling requirements.

The study followed a crackdown on energy drinks containing alcohol. A number of states banned those products and, under increasing pressure, Anheuser-Busch ended sales of energy drink products containing alcohol.

Now the FDA is looking into Monster Beverage. According to incident reports filed to the agency by doctors around the country, as many as five deaths may be tied to drinking the beverages. The incident reports also mention more than 30 other adverse reaction from drinking the beverages.

Lawmaker pushed for FDA probe

Sen. Richard Durbin (D-IL) raised the issue back in April, citing Fournier's death the previous December. In a letter to the Commissioner of the FDA, Durbin called for an investigation into energy drinks like ‘Monster Energy’, ‘Rockstar’ and ‘Red Bull’ which contain high levels of caffeine. Durbin said the drinks contain potentially dangerous ingredients yet are marketed to young people.

Fournier died of a cardiac arrhythmia. Durbin says it was due to caffeine toxicity after drinking two 24-ounce Monster energy drinks in a 24-hour period.

“Consuming large quantities of caffeine can have serious health consequences, including caffeine toxicity, stroke, anxiety, arrhythmia, and in some cases death,” Durbin wrote in the letter. “Young people are especially susceptible to suffering adverse effects because energy drinks market to youth, their bodies are not accustomed to caffeine, and energy drinks contain high levels of caffeine and stimulating additives that may interact when used in combination.”

Durbin said the FDA has the authority to regulate caffeine amounts in beverages and should exercise that authority.  

For decades, chewing gum was just, well, chewing gum. About the most you could expect to get out of it was a bubble now and then.

Nicorette changed all that; suddenly chewing gum became a delivery vehicle for nicotine, supposedly helping smokers kick the habit. Oddly, not much else happened -- no vitamin-enriched, antibacterial, gluten-free gums.

Ah, but now there's caffeinated gum, courtesy of Wm. Wrigley Jr. Co., longtime makers of such household names as Juicy Fruit and Doublemint. Instead of just doubling your fun, Wrigley's new Alert Energy Caffeine Gum promises to give you an energy jolt without the bother of glugging liquid from a bottle or gulping down pills.

But there's a lot to chew on when you get into the energy-boost market. Just ask the makers of AMP, Monster Energy Drinks and 5-hour Energy. They're facing scrutiny from the Food and Drug Administration as well as city and state regulators concerned about caffeine overdoses in younger users.

No brand extension

Hoping to avoid similar problems, Wrigley says Alert Energy is being targeted at the 25-and-up market and will not be associated with existing brands like Doublemint.

And while this may be a good idea, it's not actually a new one. Wrigley has been producing caffeinated gum for years. In 1998, it came up with a cinnamon-flavored caffeine gum intended for the military, the idea being to give combat troops a highly portable source of caffeine.

Congress funded a study on the gum's effectiveness and the results were encouraging, according to published accounts from long ago.

Among the advantages: caffeine from gum is absorbed quickly, delivering 85 percent of its dose in five minutes, compared to 45 to 90 minutes for a cup of coffee to take effect. That's because chewed nicotine is absorbed through the tissues of the mouth instead of having to travel through the digestive system. 

Among the disadvantages: the taste. Caffeine is bitter and while the cinnamon covered up some of the taste, it didn't obliterate it entirely.

A competitor, Jolt, emerged and stole some of Wrigley's thunder and was promptly sued by Wrigley for patent infringement. Meanwhile, Red Bull and similar energy drinks became popular among troops, stealing some of the gum's thunder. But both Wrigley and Jolt have continued producing more potent caffeinated gum for the military for years.

A little bitter 

In its latest attempt to get everyday Americans chewing their caffeine, Wrigley is being upfront about the taste, admitting that, although Alert comes in fruit and mint flavors, it still has a bitter, medicinal taste. But then, so do most energy drinks.  

Wrigley officials are hoping the slightly bitter taste is a reminder to customers that Alert is a gum with a purpose, not a sweet treat. No doubt the company is also hoping the taste discourages teens from abusing the gum.  

The company said a pack of Alert will sell for about $2.99 and will contain eight pieces, each packing about 40 milligrams of caffeine. That's about half the amount in an eight-ounce cup of coffee.

Regulators and health advocates have been pouring scalding criticism on high-caffeine energy drinks the last few years following reports of death and illness unofficially attributed to the potent drinks.

But now the energy drinks are fighting back. Monster Beverage, makers of Monster Energy, and Rockstar Energy are changing their labels and product descriptions to wriggle out from under the jurisidiction of the Food and Drug Administration.

Henceforth, Monster and Rockstar drinks will be marketed as beverages rather than dietary supplements. Among the advantages of the change -- the companies will not be obligated to inform the feds when they learn of deaths and injuries attributed to their products.

Monster will also be disclosing its caffeine content for the first time and the results may surprise some critics. According to the company, a 16-ounce can of Monster's leading drinks contain 140 to 160 milligrams of caffeine, less than half the 330 mg found in a 16-ounce cup of Starbucks coffee.

The moves come as criticism of the drinks grows. Earlier this week, a group of 18 doctors and researchers urged the FDA to do more to protect adolescents and children from the possible risks of high caffeine consumption.

Potential health risks

“There is evidence in the published scientific literature that the caffeine levels in energy drinks pose serious potential health risks,” they said. But Monster has been fighting back against such allegations. 

In a recent statement, Monster said a recent report linking energy drinks to emergency room visits is "highly misleading and does not support any conclusion that energy drinks are unsafe for consumers."

It said the report "does not provide enough information to determine the nature of patients' complaints, the amount of caffeine consumed from all sources, or whether there was any connection between the complaints and the consumption of an energy

drink."

"Any causal connection between energy drink consumption and emergency room visits is further substantially weakened by the existence of other factors more likely to have been responsible for the patients' medical issues, such as the use of pharmaceuticals, alcohol or illegal drugs, which was reported by 42% of patients," the company said. "This number was almost certainly under reported because many of the patients, especially those under 21, likely would have been reluctant to voluntarily admit this type of information."

Recent target

5-hour Energy was the most recent target of regulators' wrath, with the FDA charging the drinks may have caused 13 deaths and made 33 people seek hospital care.

The makers of the energy drink, Living Essentials, said it hasn’t seen any proof that would suggest its product has caused the death or hospitalization of any of its customers.

“5-hour is unaware of any deaths proven to have been caused by the consumption of 5-hour Energy,” said Living Essentials. “It is important to note that submitting a serious adverse event report to the FDA, according to the agency itself, is not construed by FDA as an admission that the dietary supplement was involved caused or contributed to the adverse event being reported.”

Nothing healthy

Could be but health and nutrition experts say there is little to recommend the drinks.

“There’s nothing healthy about energy drinks. Even though they promise an energy boost they’re often packed with sugar, calories and excessive caffeine,” said Karen Ansel, MS, RD, a spokesperson for the Academy of Nutrition and Dietetics.

Ansel says what can be dangerous about drinks like Rock Star and 5-Hour Energy is their strange combination of unnatural ingredients.

“The concern with many energy drinks on the market is that they combine many ingredients not usually found together in nature," she said in a ConsumerAffairs  interview. “As a result, people who don’t know that they have underlying conditions such as heart disease, high blood pressure or seizure disorders may unknowingly be susceptible to dangerous elevations in blood pressure and heart rate or the risk of seizures.”

“In addition, energy drinks are easy to chug much faster than you would ever drink a cup of coffee so you could end up inhaling much more caffeine than you normally would from more natural sources such as coffee or tea. The labels of some of these suggest limits as to how much is safe per day, but few people actually read the label," Ansel said.

We've all seen and heard those energy drink commercials that promise to do everything from improving your golf game to putting more zip in your sex life. That may be the least of it.

A study presented at the American Heart Association's Epidemiology and Prevention/Nutrition, Physical Activity and Metabolism 2013 Scientific Sessions found that these same drinks may increase blood pressure and disturb your heart's natural rhythm.

Researchers analyzed data from seven previously published observational and interventional studies to determine how consuming energy drinks might affect heart health.

In the first part of the pooled analysis, the researchers examined the QT interval of 93 people who had just consumed one to three cans of energy drinks. The QT interval describes a segment of the heart's rhythm on an electrocardiogram; when prolonged, it can cause serious irregular heartbeats or sudden cardiac death. They found that the QT interval was 10 milliseconds longer for those who had consumed the energy drinks.

Life-threatening consequences

"Doctors are generally concerned if patients experience an additional 30 milliseconds in their QT interval from baseline," said Sachin A. Shah, Pharm.D., lead author and assistant professor at University of the Pacific in Stockton, Calif.

"QT prolongation is associated with life-threatening arrhythmias. The finding that energy drinks could prolong the QT, in light of the reports of sudden cardiac death, warrants further investigation." said Ian Riddock, M.D., a co-author and director of preventive cardiology at the David Grant Medical Center, Travis Air Force Base, Calif.

Researchers also found that the systolic blood pressure -- the top number in a blood pressure reading -- increased an average of 3.5 points in a pool of 132 participants.

"The correlation between energy drinks and increased systolic blood pressure is convincing and concerning, and more studies are needed to assess the impact on the heart rhythm." Shah said. "Patients with high blood pressures or long QT syndrome should use caution and judgment before consuming an energy drink.

"Since energy drinks also contain caffeine, people who do not normally drink much caffeine might have an exaggerated increase in blood pressure."

The pooled studies included healthy, young patients 18-45 years old. "People with health concerns or those who are older might have more heart-related side effects from energy drinks", said Shah.

Caffeinated chewing gum has existed in relative obscurity for a long time, but when Wrigley  announced in March that it was getting in on the game with its new Alert gum, things started happening.

Competitors scrambled to get their names into the stories about Wrigley, but now they may wish they hadn't. The Food and Drug Administration (FDA) is looking at the effects of caffeine on children and, more specifically, whether chewing gum increases the risks of caffeine overdoses in kids, Bloomberg News reported.

The FDA has also been looking sternly at energy drinks like those from Monster and Living Essentials following reports of deaths and hospitalizations involving children and teens.

Not targeted to teens

Wrigley, part of the Mars candy empire, says the new gum, Alert Energy, is being targeted at the 25-and-up market and will not be associated with existing brands like Doublemint.

"Alert Energy Caffeine Gum is an energy product for adults who consume caffeine for energy and are looking for a portable solution that lets them control their caffeine intake," the company says on its website.

Could be, but that's not likely to allay the suspicions of people like Sens. Dick Durbin (D-Ill.) and Richard Blumenthal (D-Conn.) who have been pressing the FDA to convene an expert panel to study the effects of caffeine on children.

"Consuming large quantities of caffeine can have serious health consequences, including caffeine toxicity, stroke, anxiety, arrhythmia, and in some cases death," Durbin said in an April 2012 letter to the FDA. "Young people are especially susceptible to suffering adverse effects because energy drinks market to youth, their bodies are not accustomed to caffeine, and energy drinks contain high levels of caffeine and stimulating additives that may interact when used in combination,” wrote Durbin.

“The glossy marketing tailored to youth has worked -- 30 to 50 percent of adolescents report consuming energy drinks,” Durbin said. His letter calling for an investigation came after he learned of the death a 14 year-old girl from Maryland, Anais Fournier, who died in December 2011 of a cardiac arrhythmia due to caffeine toxicity after drinking two 24-ounce Monster energy drinks in a 24-hour period.

Durbin and Blumenthal have been critical of the FDA's response to their requests, saying the agency is not paying enough attention to the unique characteristics of children.

"While we recognize the FDA’s efforts to assess caffeine consumption in the United States, young people are not small adults.  Therefore determinations on the safety of caffeine should not be based solely on healthy adults," Durbin said in a follow-up letter in September 2012. "We ask the FDA to include adolescents and children in their assessment of the safety risks posed by consuming high levels of caffeine, such as those in energy drinks."

Not a new idea

Wrigley and other companies have been producing caffeinated gum for years but distribution has been limited mostly to the military and other specialized markets. In 1998, it came up with a cinnamon-flavored caffeine gum intended for the military, the idea being to give combat troops a highly portable source of caffeine.

Although it is effective at delivering caffeine, the gum has a somewhat bitter taste. Wrigley is now trying to turn that into an asset.

Wrigley officials are hoping the slightly bitter taste is a reminder to customers that Alert is a gum with a purpose, not a sweet treat. No doubt the company is also hoping the taste discourages teens from abusing the gum.  

The company said a pack of Alert will sell for about $2.99 and will contain eight pieces, each packing about 40 milligrams of caffeine. That's about half the amount in an eight-ounce cup of coffee.

A high-energy legal battle is shaping up in San Francisco, where the city has sued Monster Beverage and Monster Beverage has sued San Francisco. The dispute revolves around the city's claims that Monster targets its advertising to kids.

It's the latest round in a nationwide tussle over energy drinks and other caffeinated products. On Friday, Wrigley withdrew its Alert Energy caffeinated chewing gum saying it was responding to concerns expressed by the U.S. Food and Drug Administration (FDA).

Monster, the largest maker of energy drinks in the U.S., claims in its suit that San Francisco District Attorney Dennis Herrera is overstepping his authority by trying to require it to curb its advertising and serving sizes.

But Herrera's not buying it.

"Monster Energy is unique among energy drink makers for the extent to which it targets children and youth in its marketing, despite the known risks its products pose to young people's health and safety," he said. "Consumption of highly caffeinated energy drinks by children has been widely condemned by pediatricians and scientists, and the NCAA has banned its member institutions from providing these products even to college athletes because of the grave safety risks."

Remains defiant

Herrera said Monster Energy has remained defiant even in the face of the FDA's expressions of concern.

"As the industry's worst offender, Monster Energy should reform its irresponsible and illegal marketing practices before they're forced to by regulators or courts," Herrera said in a prepared statement.

Herrera's lawsuit came one week after Monster pre-emptively sued Herrera in an legal attempt to halt his office's months-long investigation into Monster's marketing and sales practices.

"Mr. Herrera appears to be motivated by publicity rather than fact or science," a Monster spokesman said.

A California woman is suing Monster Beverage Corp., claiming her son died of a heart attack brought on by ingesting a "toxic amount of caffeine and other stimulants."

Paula Morris says her son, Alex, 19, was having sex with his girlfriend when he went into cardiac arrest and died. He had earlier downed two Monster Energy drinks, the suit alleges, Courthouse News Service reported.

The suit says that the youth had regularly consumed at least two 16-ounce cans of Monster Energy drinks per day for the past three years.  He died during the early morning hours of July 1, 2012, after becoming unresponsive while having a sexual encounter with his girlfriend.

An autopsy report identifies the cause of death as "cardiac arrhythmia due to cardiomyopathy," the complaint states.

"Massive amount"

Morris claims Monster Energy loads its drinks with "massive amounts of caffeine" though it knows that excessive caffeine consumption can cause many health problems, including heart arrhythmia.

"In addition to caffeine, Monster Energy drinks contain guarana and taurine. Guarana is a plant extract that contains caffeine. Taurine has an effect on cardiac muscles similar to that of caffeine. Studies have shown that the synergistic effect of caffeine, guarana, taurine and/or other like substances can produce significant adverse health effects, including cardiac arrest," the complaint states.

Morris claims Monster conceals the risks associated with drinking its products through misleading advertisements, labels and promotions that assure consumers they are safe.

She says her son would not have drunk two Monster Energy drinks a day for three years if Monster had "properly disclosed and warned of the significant risk of suffering adverse cardiac episodes."

The suit, filed in Alameda County, Calif., court, seeks punitive damages for wrongful death, product liability, negligence, fraudulent concealment and other charges. She also seeks medical expenses and funeral costs. She is represented by Alexander Wheeler with the R. Rex Parris Law Firm in Lancaster, Calif., and Kevin Goldberg with Goldberg, Finnegan & Mester of Silver Spring, Md.

Time is money. And, according to the Centers for Disease Control and Prevention (CDC), so is booze.

According to a new study released by the CDC, excessive alcohol use causes a large economic burden to states and the District of Columbia -- a median of $2.9 billion in 2006 to put it dollar-terms. That ranges from $420 million in North Dakota to $32 billion in California. And it works out to a median cost of $1.91 per state for each alcoholic drink consumed.

Binge drinking -- consuming five or more drinks on an occasion for men or four or more drinks on an occasion for women -- was responsible for more than 70% of excessive alcohol use related costs in all states and D.C. The District had the highest per-person cost ($1,662), while Utah had the highest cost per drink ($2.74). Furthermore, about $2 of every $5 in state costs were paid by government, ranging from 37% of the costs in Mississippi to 45% of the total costs in Utah.

Wide-ranging costs

Study authors found that costs due to excessive drinking largely resulted from losses in workplace productivity, health care expenses, and other costs due to a combination of criminal justice expenses, motor vehicle crash costs, and property damage.

Across all states and D.C., excessive drinking costs due to productivity losses ranged from 61% in Wyoming to 82% in D.C., and the share of costs due to health care expenses ranged from 8% in Texas to 16% in Vermont.

“This study alerts states to the huge economic impact of excessive alcohol use, and shows how it affects all of us by reducing productivity, increasing criminal justice expenses, and increasing healthcare costs,” said CDC Director Tom Frieden, M.D., M.P.H. “Effective prevention programs can support people in making wise choices about drinking alcohol, and help reduce the huge personal and social costs of excessive drinking.”

May be low-balling

Economic cost estimates for states and D.C. were based on a previous CDC study that found that excessive drinking cost the United States $223.5 billion in 2006. Costs were assessed across 26 cost categories using data from several sources, including the Alcohol-Related Disease Impact Application, the National Epidemiologic Survey on Alcohol-Related Conditions, and the National Survey on Drug Use and Health.

Researchers believe that the study’s findings are underestimated because it did not consider a number of other costs, such as those due to pain and suffering by the excessive drinker or others who were affected by the drinking.

“It is striking to see most of the costs of excessive drinking in states and D.C. are due to binge drinking, which is reported by about 18% of U.S. adults,” said Robert D. Brewer, M.D., M.S.P.H., Alcohol Program Lead at CDC and one of the authors of the report. “Fortunately, the Community Guide includes a number of effective strategies that states and localities can use to prevent binge drinking and the costs related to it.”

Excessive alcohol consumption is responsible for an average of 80,000 deaths and 2.3 million years of potential life lost in the United States each year. Binge drinking is responsible for over half of these deaths and two-thirds of the years of life lost.   

The holiday season means parties and special meals with family and friends, where the wine and spirits flow freely. Sometimes a little too freely.

A new survey finds that many people are not aware of what high-risk alcohol consumption looks like. Not only do they not recognize it in those around them, they don't recognize it in themselves.

"Alcohol is still the number one cause of damaging behavior at holiday celebrations throughout the U.S.," said Dr. Harris Stratyner, Regional Clinical Vice President of Caron Treatment Centers in New York, which commissioned the survey. "We tend to see an increase in alcohol abuse during the holidays and the findings show that many people have no sense of how much alcohol is healthy to consume or how it impairs them when they go past that low-risk limit. It's a serious public safety concern when 60% of adults who attend holiday parties witnessed dangerous and even illegal behavior."

Low-risk drinking

To recognize high-risk drinking it might be helpful to start with what constitutes low-risk drinking. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) sets the boundary of low-risk consumption as no more than four drinks per day for men and no more than three drinks per day for women.

However, drinking at that pace on a daily basis would clearly place you in high-risk territory. The NIAAA says men should limit themselves to no more than 14 drinks per week and women should have no more than seven drinks in that time.

It goes without saying that holiday parties and gatherings can be enjoyable without alcohol consumption but many find a drink or two adds to the spirit of the occasion. And if you are inclined to over-indulge, the holidays just seem to bring that out.

The survey found that 60% of those who attended office holiday parties have seen someone under the influence of alcohol behave inappropriately. Inappropriate or embarrassing behavior included an intoxicated male colleague who "slapped a female co-worker on her bottom" and another who "threw up on the boss."

Families that drink together...

Even family gatherings – perhaps especially family gatherings – can be marred by too much alcohol. Nearly two-thirds of respondents reported attending a family holiday function where a family member behaved inappropriately after drinking too much alcohol. The inappropriate behavior included "a knock out drag out fist fight," though most of the abusive behavior detailed in the survey was verbal.

While recognizing high-risk drinking in your own behavior is very important, it is increasingly important to recognize it in others if you are the host of a holiday party, whether its an office party or a private affair with family and friends.

If you are the host and someone leaves your home in an intoxicated state and gets into an accident, you could be legally exposed. To steer clear of trouble, legal experts suggest providing plenty of filling food and non-alcoholic beverages at the gathering. Have a designated bartender – don't let guests serve themselves. Stop serving alcohol well before the party ends and be ready to arrange transportation home for a guest who gets tipsy.

Dangers of an office party

The liability risks may be greater for a business hosting an office party. The best way to avoid exposure is to not serve alcohol. However, if you are serving liquor, limit consumption.

One way to do that is to provide attendees with two tickets each for drinks. Avoid serving up alcohol-laced punch, since some people may gulp it down without realizing how much alcohol they're consuming.

Some companies make a point of holding office holiday parties off-site, getting it completely out of the business environment. Some companies have even provided taxi vouchers to pay for cab ride homes, but legal experts caution you should take no steps that could be seen as encouraging alcohol consumption.

Whether it is a business or private function, those who treat alcohol addiction want attendees and hosts both to be mindful of keeping their alcohol use in check. Because if there is a problem with alcohol, it almost always shows itself during the holidays.

"We want to help individuals and families change their perception about what healthy alcohol consumption actually looks like and empower them to seek help for substance abuse," said Paul Hokemeyer, Senior Clinical Advisor at Caron.

Although it's a major health problem in the United States, alcohol abuse is a topic that rarely comes up between physicians and their patients.

A new Vital Signs report from the Centers for Disease Control and Prevention (CDC) says only one in six adults -- and only one in four binge drinkers -- say a health professional has ever discussed alcohol use with them.

Even among adults who binge drink 10 or more times a month, only one in three have ever had a health professional talk with them about alcohol use. Binge drinking is defined as consuming four or more drinks for women and five or more drinks for men within 2-3 hours. Talking with a patient about alcohol use is an important first step in screening and counseling, which has been proven effective in helping people who drink too much to drink less, according to CDC.

A drink is defined as five ounces of wine, 12 ounces of beer, or 1.5 ounces of 80-proof distilled spirits or liquor.

The toll of alcohol abuse

At least 38 million adults in the U.S. drink too much. Most are not alcoholics. Drinking too much causes about 88,000 deaths each year, and was responsible for about $224 billion in economic costs in 2006. It can also lead to many health and social problems, including heart disease, breast cancer, sexually transmitted diseases, fetal alcohol spectrum disorders, motor-vehicle crashes and violence.

Alcohol screening and brief counseling can reduce the amount of alcohol consumed on an occasion by 25% among those who drink too much. It is recommended for all adults, including pregnant women. As with blood pressure, cholesterol and breast cancer screening, and flu vaccination, it has also been shown to improve health and save money.

“Drinking too much alcohol has many more health risks than most people realize,” said CDC Director Tom Frieden, M.D., M.P.H. “Alcohol screening and brief counseling can help people set realistic goals for themselves and achieve those goals. Health care workers can provide this service to more patients and involve communities to help people avoid dangerous levels of drinking.”

The screening process

Health professionals who conduct alcohol screening and brief counseling use a set of questions to screen all patients to determine how much they drink and assess problems associated with drinking. This allows them to counsel those who drink too much about the health dangers, and to refer those who need specialized treatment for alcohol dependence. CDC used 2011 Behavioral Risk Factor Surveillance System data to analyze self-reports of ever being “talked with by a health provider” about alcohol use among U.S. adults aged 18 and older from 44 states and the District of Columbia.

No state or district had more than one in four adults report that a health professional talked with them about their drinking, and only 17% of pregnant women reported this. Drinking during pregnancy can seriously harm the developing fetus.

Four Loko has agreed to pay $400,000 and clean up its marketing practices.

It's part of a multistate settlement of allegations that the company unlawfully marketed its flavored malt beverages, promoted the misuse of alcohol by underage individuals, and failed to disclose the effects of drinking alcoholic beverages combined with caffeine.

Four Loko has also agreed to change how it markets and promotes its flavored malt beverages and other alcoholic products, Massachusetts Attorney General Martha Coakley said.

Public health concerns

“Binge drinking and underage drinking are public health concerns, and it is essential that companies market their products responsibly, particularly when they are selling alcoholic products that may appeal to minors,” Coakley said. “We are pleased that the company will improve the marketing and promotion of its flavored malt beverages to prevent dangerous drinking behaviors.”

Coakley joined 19 other attorneys general and the City Attorney of San Francisco in pursuing changes to the marketing and sales practices of Phusion Products LLC, Four Loko's parent compay.

The settlement specifically addresses Phusion’s practice of manufacturing, marketing, and selling unsafe and adulterated caffeinated alcoholic beverages prior to the FDA’s November 2010 letter warning Phusion that caffeinated Four Loko is an unsafe product.

As a result, Phusion ceased producing caffeinated alcoholic beverages, marketed as energy drinks, and removed its caffeinated Four Loko products from retail store shelves. Phusion later reintroduced the malt beverage without caffeine and other ingredients.

As part of the settlement, Phusion has agreed to reform how it markets and promotes its flavored malt beverages, including Four Loko, and to stop promoting the use of alcohol by minors.

States joining the settlement include Arizona, Connecticut, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland, Mississippi, New Mexico, New York, North Carolina, Ohio, Oregon, Pennsylvania, Tennessee, and Washington, along with the City Attorney of San Francisco.

The good news is that children in the U.S. are drinking less sugar and caffeine-laden soda. The bad news is a reported rise in youthful consumption of energy drinks, which are loaded with caffeine.

An early 2014 report by the Centers for Disease Control and Prevention (CDC) found that energy drinks are responsible for increases in caffeine consumption by children and teens.

"You might expect that caffeine intake decreased, since so much of the caffeine kids drink comes from soda," said the study's lead author, Amy Branum, a statistician at the CDC's National Center for Health Statistics. "But what we saw is that these decreases in soda were offset by increases in coffee and energy drinks."

The portion of the rise in caffeine consumption attributed to energy drinks isn't particularly large. But what's troubling to some public health policymakers is that just a few years ago it was almost non-existent.

Unregulated

The CDC estimates that 30% to 50% of adolescents and young adults consume energy drinks that can contain large amounts of caffeine – much more than found in soda products. Of equal concern to many public health experts is the fact that the caffeine in these products is largely unregulated.

The lack of regulation extends to the products' label. Caffeine might be listed as an ingredient but it doesn't show up on the nutrition label. Product advertising certainly doesn't mention it.

Ruth Litchfield, an associate professor and associate chair of food science and human nutrition at Iowa State University says the result is huge consumer misperceptions about these products.

She points out that the recent CDC study found 20% of young people who consume energy drinks think they are safe and 13% believe energy drinks are a type of sports drink.

“These drinks have this connotation that they are a performance enhancer because they’re an energy drink,” Litchfield said. “Whether that performance is academic or physical, that’s the perception.”

Misperception

The misperception is not limited to young consumers. Litchfield said she has witnessed adults in the grocery store buying energy drinks – containing the caffeine equivalent of 5 cups of coffee – for their children.

Besides caffeine – which gives energy drinks their kick – many energy drinks also contain ma huang – also going by the name ephedra – and guarana. Both substances are stimulants and – like caffeine – are not required to be listed on the nutrition label.

The Food and Drug Administration (FDA) recently introduced changes to the nutrition labels on food and beverages but the revamped label still has no requirement for listing caffeine. And nutrition labels rarely appear on energy drinks anyway. Instead you'll usually find a “supplement facts” label.

Health risks

Not only are young consumers unaware of how much caffeine they are getting in an energy drink, they may not even be aware of the stimulants' health risks. Litchfield says the amount of caffeine young people increasingly consume has health implications.

“Your heart rate and blood pressure will increase and you’ll have increased risk for arrhythmias,” she said. “If you consistently consume these for a prolonged period of time, you’re increasing your risk for cardiovascular disease.”

And there may not be as many – or any – positive effects from gulping down energy drinks. According to researchers at the University of California Davis, it's just assumed that these products hold special invigorating properties because they are loaded with stimulants.

“There is limited evidence that consumption of energy drinks can significantly improve physical and mental performance, driving ability when tired, and decrease mental fatigue during long periods of concentration,” the authors write.

Currently people with alcohol dependence have few treatment options. In most cases they enter programs in which the goal is complete and lifelong abstinence from alcohol.

For many who are committed to overcoming their alcohol dependence these programs are highly successful. Others, however, fall by the wayside and return to excessive drinking.

Now researchers at the University of North Carolina believe several readily available medications that can help maintain abstinence or reduce the amount of alcohol they drink.

"There are many studies that have tried to show whether certain medications can help with alcohol use disorders, but it is a lot of information to digest and many providers do not know what works or doesn't work," said Daniel Jonas, lead author of the study. "When you synthesize all the evidence, it shows pretty clearly that some medications do work."

The study is published in the Journal of the American Medical Association (JAMA) and funded by the Agency for Healthcare Research and Quality (AHRQ), a federal agency. It offers some additional options for doctors to help patients with alcohol dependency.

At present fewer than one-third of people with alcohol disorders receive any treatment and fewer than 10% receive medications to help reduce alcohol consumption.

What works

Jonas and his research team conducted a systematic review of 122 randomized trials and one cohort study. They conclude that two drugs, acamprosate – brand name Campral -- and oral naltrexone – brand name Revia -- have the best evidence supporting their benefits.

According to the findings both drugs reduced subjects' resumption of drinking and improved other alcohol-related outcomes.

The research also identified two other drugs – topiramate and nalmefene – that are not approved for alcohol disorders but showed some improvement in outcomes for those taking them.

"The health implications of preventing a return to drinking and reducing alcohol consumption are substantial," Jonas said. "Modeling studies have shown that such improvements would result in significant reductions in alcohol-attributable mortality, costs from health care, arrests and motor vehicle accidents."

In addition to accidents, there are many other health-related issues stemming from drinking too much alcohol. The link between alcohol and cirrhosis of the liver is well established. Alcohol abuse has also been linked to various cancers, stroke and depression.

Growing problem among seniors

Alcohol abuse has increased in recent years, not just among young people but among their grandparents as well. Alcohol and prescription drug problems among adults 60 and older is one of the fastest growing health problems facing the country, according to the National Council on Alcoholism and Drug Dependence.

As people age their ability to metabolize alcohol declines. The National Institute on Alcohol Abuse and Alcoholism, part of the National Institutes of Health, recommends that people over age 65 should have no more than seven drinks a week and no more than three drinks on any one day.

Jonas and his research team believe doctors should take advantage of available drugs to help patients of all ages reduce or stop drinking. But first doctors will have to bring up the subject with their patients, and a Centers for Disease Control and Prevention (CDC) report suggests that isn't happening.

The CDC reports only 1 in 6 adults -- and only 1 in 4 binge drinkers -- say a health professional has ever discussed alcohol use with them.  

Thinking about a wild weekend? You may want to reconsider.

A report from the Centers for Disease Control and Prevention (CDC) says excessive use of alcohol accounts for one in 10 deaths among U.S. working-age adults ages 20-64 years.

According to the report, published in Preventing Chronic Disease, excessive alcohol use led to approximately 88,000 deaths per year from 2006 to 2010, and shortened the lives of those who died by about 30 years.

These deaths, the report says, were due to health effects from drinking too much over time, such as breast cancer, liver disease, and heart disease; and health effects from drinking too much in a short period of time, such as violence, alcohol poisoning, and motor vehicle crashes.

In total, there were 2.5 million years of potential life lost each year due to excessive alcohol use.

“It’s shocking to see the public health impact of excessive drinking on working-age adults,” said Robert Brewer, M.D., M.S.P.H., head of CDC’s Alcohol Program and one of the report’s authors. “CDC is working with partners to support the implementation of strategies for preventing excessive alcohol use that are recommended by the Community Preventive Services Task Force, which can help reduce the health and social cost of this dangerous risk behavior.”

Men most at risk

Nearly 70% of deaths due to excessive drinking involved working-age adults, and about 70% of the deaths involved males. About 5% of the deaths involved people under age 21.

The highest death rate due to excessive drinking was in New Mexico (51 deaths per 100,000 population), and the lowest was in New Jersey (19.1 per 100,000).

“Excessive alcohol use is a leading cause of preventable death that kills many Americans in the prime of their lives,” said Ursula E. Bauer, Ph.D., M.P.H., director of CDC’s National Center for Chronic Disease Prevention and Health Promotion. “We need to redouble our efforts to implement scientifically proven public health approaches to reduce this tragic loss of life and the huge economic costs that result.”

How much is too much?

Excessive drinking includes binge drinking (4 or more drinks on an occasion for women, 5 or more drinks on an occasion for men), heavy drinking (8 or more drinks a week for women, 15 or more drinks a week for men), and any alcohol use by pregnant women or those under the minimum legal drinking age of 21.

Excessive drinking cost the U.S. about $224 billion, or $1.90 per drink, in 2006. Most of these costs were due to lost productivity, including reduced earnings among excessive drinkers as well as deaths due to excessive drinking among working age adults.

The independent HHS Community Preventive Services Task Force recommends several evidence-based strategies to reduce excessive drinking. These include increasing alcohol taxes, regulating alcohol outlet density, and avoiding further privatization of alcohol retail sales.

The death of an 18-year-old Ohio student is leading to warnings about the use of pure caffeine powder, a powerful stimulant that's becoming popular among weightlifters and other athletes.

The warnings follow the May 27 death of Logan Stiner, 18, a high school senior, athlete and prom king. Health officials in LaGrange, Ohio, say Stiner had 70 micrograms of caffeine per milliliter of blood in his system, about 14 times as much as a typical coffee drinker.

The U.S. Food and Drug Administration said it is especially concerned about the sale of powdered caffeine on the Internet, making it easy for teens to make purchases without their parents' knowledge. The substance is easily found at Amazon.com and on Google Shopping.

AllStarHealth.com offers a 200-gram container of powdered caffeine for $10.99. It recommends using a single scoop (1,000 mg) with 8 ounces of water and warns against mixing it with other caffeinated beverages.

"Pure caffeine is a powerful stimulant and very small amounts may cause accidental overdose. Parents should be aware that these products may be attractive to young people," the FDA said in a warning to consumers.

"Symptoms of caffeine overdose can include rapid or dangerously erratic heartbeat, seizures and death. Vomiting, diarrhea, stupor and disorientation are also symptoms of caffeine toxicity. These symptoms are likely to be much more severe than those resulting from drinking too much coffee, tea or other caffeinated beverages," the agency said.

People with pre-existing heart conditions should be especially careful not to use any type of powdered caffeine, the FDA cautioned.

Not enough

The FDA's warning is a step in the right direction, but doesn't go far enough, some health advocates argue.

"FDA should take whichever additional measures it can against these products, and it has much more to do if it really wants to protect the public," said Jim O'Hara, Health Promotion Policy Director at the Center for Science in the Public Interest. "The overuse and misuse of caffeine in the food supply is creating a wild-west marketplace, and it’s about time the sheriff noticed and did something."

Athletes who consume energy drinks to give them a competitive edge might in fact get a boost in energy, but could pay for it later.

Researchers at Camilo José Cela University (UCJC) say they found athletes who use energy beverages were more likely to report insomnia and nervousness in the hours after the competition.

In the 4-year study, athletes in a variety of vigorous sports consumed the equivalent of 3 cans of energy drink or an energy drink placebo before a sports competition. Sporting performance was measured with the use of GPS devices that determined the distance and the speed at which athletes moved.

The researchers also employed other sophisticated equipment to measure muscle performance. Published in the British Journal of Nutrition, the results show that athletes who used energy drinks increased their sporting performance by between 3% and 7%.

Juan Del Coso Garrigós, one of the study authors, says energy drinks do in fact make basketball players jump higher, increase muscle force and power for climbers and trained individuals, swimming speed for sprinter swimmers, hit force and accuracy for volleyball players and the number of points scored in tennis.

Insomnia and nervousness

That's the good news. But once the sport competition is over, it isn't exactly back to normal.

These studies asked athletes about their sensations after consuming the energy drink and measured the frequency of the side effects in comparison with the placebo drink.

"Athletes felt they had more strength, power and resistance with the energy drink than with the placebo drink," said Del Coso. "However, the energy drinks increased the frequency of insomnia, nervousness and the level of stimulation in the hours following the competition".

Maybe it shouldn't come as a surprise that the consumption of energy drinks produced an increase in the side effects typically found with other caffeinated drinks. The researchers said they found no significant differences between male and female athletes in the perception of positive sensations, nor in the apparition of side effects.

"Caffeinated energy drinks are a commercial product that can significantly increase sporting performance in many sports activities," said Del Coso. "The increase in their consumption is probably driven by the hard advertising campaigns of energy drink companies related to sports sponsorships."

Not that much energy

Energy drinks are made up of mostly carbohydrates, caffeine, taurine and B vitamins. From brand to brand, there is little difference in the quantities and ingredients.

Despite being labeled as energy drinks, the researchers say they don't really provide more energy than other soft drinks. Instead, they have an 'energizing' effect, due mainly to the caffeine they contain.

Del Coso maintains that none of the other ingredients in energy drinks actually produce a significant effect on physical or mental performance.

The average energy drink can contain from 75 to over 200 milligrams of caffeine per serving. Health experts at Brown University say this compares to 34 milligrams in Coke and 55 milligrams in Mountain Dew.

If the beverage is labeled “no caffeine,” the energy comes from guarana, which is the equivalent of caffeine. The Brown experts note that 5-hour energy advertises “no crash,” but says this claim is referring to no “sugar crash” because the drink has artificial sweetners.

Planning your New Year's Eve celebration? You may want to pause a moment to review a new study that finds binge drinking in young, healthy adults significantly disrupts the immune system.

In the study, led by a researcher now at Loyola University Chicago Stritch School of Medicine, study participants drank four or five shots of vodka, depending on their weight.

Twenty minutes after reaching peak intoxication, their immune systems revved up. But when measured again, at two hours and five hours after peak intoxication, their immune systems had become less active than when sober. The study included eight women and seven men with a median age of 27.

The study led by Majid Afshar, MD, illustrates a potentially harmful effect of binge drinking that is not widely recognized, unlike the falls, burns, gunshot wounds, car accidents and other traumatic injuries generally associated with heavy drinking. One-third of trauma patients have alcohol in their systems.

In addition to increasing the risk of traumatic injuries, binge drinking impairs the body's ability to recover from such injuries. Previous studies have found, for example, that binge drinking delays wound healing, increases blood loss and makes patients more prone to pneumonia and infections from catheters. Binge drinkers also are more likely to die from traumatic injuries.

Less awareness

Drinkers generally understand how binge drinking alters behavior. "But there is less awareness of alcohol's harmful effects in other areas, such as the immune system," said Elizabeth Kovacs, PhD, a co-author of the study and director of Loyola's Alcohol Research Program.

The National Institute on Alcohol Abuse and Alcoholism defines binge drinking as drinking enough to reach or exceed a blood alcohol content of .08, the legal limit for driving.

This typically occurs after four drinks for women or five drinks for men, consumed in two hours. One in six U.S. adults binge drinks about four times a month, and binge drinking is more common in young adults aged 18 to 34, according to the Centers for Disease Control and Prevention.

Dr. Afshar is planning a follow-up study of burn unit patients. He will compare patients who had alcohol in their system when they arrived with patients who were alcohol-free. He will measure immune system markers from each group, and compare their outcomes, including lung injury, organ failure and death.

The study is published online ahead of print in Alcohol, an international, peer-reviewed journal.

“Everything in moderation,” the old saying goes. It particularly applies to alcohol consumption.

In recent years health officials have worried about the increasing tendency of some people to “binge” drink, consuming multiple alcoholic beverages in a short period of time. This pattern often develops during the college years.

The National Institute on Alcohol Abuse and Alcoholism defines binge drinking as a pattern of drinking that brings blood alcohol concentration (BAC) levels to 0.08 g/dL. This typically occurs after 4 drinks for women and 5 drinks for men in about 2 hours.

Many of the dangers of binge drinking are fairly obvious. Accidents are much more likely when you are intoxicated. Over time, binge drinking can bring on serious health effects.

Alcohol poisoning

One often-overlooked danger, health officials say, is binge drinkers might die of alcohol poisoning. A new report from the Centers for Disease Control and Prevention (CDC) reveals that more than 2,200 people in the U.S. die each year from alcohol poisoning – consuming too much alcohol in too short a period of time.

When this happens it often results in very high levels of alcohol in the body, which can shut down critical areas of the brain that control breathing, heart rate, and body temperature - resulting in death.

A lot of people are at risk, perhaps more than you might think. The CDC says more than 38 million U.S. adults report binge drinking an average of 4 times per month, consuming an average of 8 drinks per binge.

CDC scientists analyzed deaths from alcohol poisoning among people aged 15 and older, using multiple cause-of-death data from the National Vital Statistics System for 2010-2012. Alcohol showed up as a contributing factor in about 30% of the deaths.

While that's more than the researchers were expecting to find, they conclude that the actual number is probably higher.

"Alcohol poisoning deaths are a heartbreaking reminder of the dangers of excessive alcohol use, which is a leading cause of preventable deaths in the U.S.," said CDC Principal Deputy Director Ileana Arias. "We need to implement effective programs and policies to prevent binge drinking and the many health and social harms that are related to it, including deaths from alcohol poisoning."

Make it cost more

Researchers at Boston University who have studied binge drinking from a policy angle say higher taxes on alcoholic beverages may be the answer.

The study found that a 1% increase in alcohol beverage prices from taxes resulted in a 1.4% decrease in the proportion of adults who binge drink. Most previous studies have examined the effect of taxes on average consumption, while the effect of taxes on high-level drinking has been controversial.

"This is really significant for public health," said lead author Ziming Xuan.

Xuan says binge drinking causes more than half of nearly 90,000 alcohol-attributable deaths in the U.S. each year, and accounts for three-quarters of the $224 billion in annual economic costs.

The study shows that as combined alcohol taxes rise, binge drinking rates fall, with taxes accounting for some 20% of the difference in binge drinking prevalence rates across the states.

The state with the highest beer combined taxes - Tennessee--had the lowest binge drinking rate in 2010, the study found. Conversely, states with low alcohol taxes, such as Montana, Wisconsin and Delaware, had relatively high binge drinking rates.

We once heard of a would-be scam artist who tried to market powdered water. "Just add water!" his ad proclaimed. It might have been a prank. No one is quite sure.

But powdered alcohol? It sounds like a prank as well but it's not. The Alcohol and Tobacco Tax and Trade Bureau -- a federal agency perhaps best known for approving viticultural, or wine-growing, regions -- has given its approval to a product called Palcohol.

But don't rush out to the corner liquor store just yet. For starters, the company says it has to gear up its production facility but hopes to have the powdery substance on the market by this summer.

The other hitch is that alcohol sales are regulated by the states as well as the feds and many states are less than enthused about the whole idea.

For their parts, the feds say their approval isn't based on whether powdered alcohol is a keen idea but simply on whether the label accurately describes the contents. By law, that's all it can consider.

Why would anybody think this is a good idea? Well, company founder Mark Phillips lists several reasons on the Palcohol website. 

• Outdoor Activity Applications: Palcohol is a boon to outdoors enthusiasts such as campers, hikers and others who wanted to enjoy adult beverages responsibly without having the undue burden of carrying heavy bottles of liquid.

• Travel Applications: Similarly, adult travelers journeying to destinations far from home could conveniently and lawfully carry their favorite cocktail in powder format. Moderate quantities of flavored Palcohol products carried in resealable pouches are a fraction of the weight and bulk associated with traditional liquor packaging.

• Hospitality Applications: Because powdered alcohol is so light, airlines can reduce the weight on an airplane by serving powdered vs. liquid alcohol and save millions on fuel costs. An ice cream manufacturer wants to add Palcohol to their ice cream to make an "adult" version. A hotel in Hawaii is interested in powdered alcohol because it would save them so much on shipping from the mainland. That savings in shipping costs would be attractive to many resorts who rely on imported alcohol.

In other words, Palcohol would make it easier and cheaper to drink. Whether this is a good thing isn't for us to say but Palcohol's opponents include the liquor industry and some state legislators, who say they fear an outbreak of abuse. 

Colorado, where marijuana is legal, last month passed a measure that temporarily outlaws powdered alcohol. Other states are considering similar easures.

"We moved to keep this potentially dangerous product out of Virginia because we knew that federal approval was pending and it would be difficult to address the problem after the fact," said Virginia Attorney General Mark Herring. "I'm glad the General Assembly agreed it was the right move to protect Virginians, especially young people, because the risk of abuse and misuse is just so high with this product."

Results of a recent animal study funded by the National Institute on Alcohol Abuse and Alcoholism suggest that carrying a gene variant that affects the release of a specific brain protein may put one at greater risk of developing an alcohol use disorder.

Scientists led by Professor Dorit Ron, PhD, Endowed Chair of Cell Biology of Addiction, Department of Neurology, University of California, San Francisco, found that mice carrying the Met68BDNF gene variant, which reduces the release of brain-derived neurotrophic (BDNF) factor, would consume excessive amounts of alcohol, despite negative consequences.

BDNF plays a role in the survival of existing neurons and the growth of new neurons and synapses, the junctures through which cell-to-cell communication occurs. The human form of this gene variant, Met66BDNF, leads to a reduction in the normal function of BDNF in the brain and is associated with several psychiatric disorders, including schizophrenia and depression.

In an animal study reported earlier this year, NIAAA-supported scientists found that adolescent binge drinking was linked to lower levels of brain-derived neurotrophic factor, and these changes persisted into adulthood.

“Genetic factors play a role in determining who develops alcohol problems,” said Dr. George Koob, PhD, NIAAA Director. “By understanding the genetic underpinnings of alcohol use disorder, we will be better able to develop targeted treatment and prevention strategies.”

Alcohol addiction in mice

In the study, published in Biological Psychiatry, researchers tested the role of BDNF in alcohol addiction by creating a “knock-in” mouse carrying Met68BDNF. In this variant, the amino acid valine (Val) is replaced by methionine (Met) in a specific position within the protein sequence of BDNF, resulting in reduced activity-dependent BDNF release.

These “knock-in” mice drank more alcohol, even when the alcohol was treated with bitter-tasting quinine. This suggests Met68BDNF carriers compulsively drink alcohol despite aversive consequences.

The effect of the genetic mutation seemed to be specific to alcohol consumption since the mice did not differ in their consumption of other fluids, or exhibit differences in levels of anxiety or compulsive behaviors

Practical application

Significantly, researchers were able to reverse compulsive alcohol drinking in the mice using gene delivery and pharmacology. Increasing levels of BDNF in the ventromedial portion of the prefrontal cortex, a brain region involved in compulsive drug and alcohol seeking, returned the mice to moderate levels of alcohol intake.

In addition, by administering a pharmaceutical compound developed to mimic the action of BDNF, researchers were also able to put a stop to compulsive drinking behaviors. This compound (LM22A-4) may have potential as a therapeutic for humans. It appears to reduce compulsive alcohol drinking without a generalized effect on motivation.

Alcohol use disorder affects about 16.6 million U.S. adults. Knowing whether patients carry a gene that results in decreased BDNF function could help in tailoring alcohol prevention and treatment strategies in the future.

In the dog days of summer, it is important to stay hydrated. But what you drink is important. Replenishing your bodily fluids with water is best.

The American Heart Association notes that sources of water also include foods, such as fruits and vegetables which contain a high percentage of water. Sports drinks with electrolytes may help with high intensity, vigorous exercise in very hot weather, though they tend to be high in added sugars and calories.

In hot weather, or after strenuous exercise, sugary drinks, alcohol, and energy drinks are not recommended.

The energy drinks now available for purchase no longer contain alcohol, but they were popular items before 2010. Even though these beverages are off the market, health officials worry that consumers are making their own, combining alcohol with the energy drinks that are currently available.

Reduce feeling of intoxication

Doctors at the Mayo Clinic say this practice can lead to problems. They say energy drinks will reduce the feeling of intoxication, meaning people drinking the beverages are prone to drinking too much.

To test this theory, researchers for the Research Society on Alcoholism selected 26 adults to participate in six double-blind sessions that involved drinking alcohol and energy drinks, alone and in combinations.

Over the course of the study, the subjects received one of six possible combinations:

• Vodka mixed with a decaffeinated soft drink
• Vodka mixed into a medium energy drink
• Vodka mixed into a large energy drink
• A decaffeinated soft drink
• A medium energy drink
• A large energy drink.

The findings

After consuming the beverages, each participant was checked for the concentration of alcohol in their breath and their desire to consume more alcohol.

Those who just drank alcohol wanted more alcohol, which was expected. But those who drank the alcohol-energy drink combination expressed an even greater desire for more alcohol.

The study provides laboratory evidence that mixing alcohol with energy drinks could lead someone to consume more alcohol than they would ordinarily.

The Mayo doctors say that for most people, an occasional energy drink is fine, but consumers should avoid spiking it with alcohol.

The Heart Association suggests avoiding energy drinks or beverages with caffeine during hot weather or exercise, noting that caffeine acts as a diuretic and causes you to lose more fluids.  

A new study from Loyola Medicine and Loyola University Chicago shows that drinking excessive amounts of alcohol is not only bad for your liver – it can also have a severe impact on your lungs.

Researchers have found that those who drink alcohol have less nitric oxide in their lungs than those who do not. This is important because nitric oxide helps protect these vital organs from harmful bacteria that often cause infection.

Dr. Majid Afshar, lead author of the study, confirms the finding, saying that “alcohol appears to disrupt the healthy balance in the lung.” He and his colleagues believe that their findings could be important to those who abuse alcohol and those who are affected by asthma, since altered levels of nitric oxide could create complications with medication.

Increased risk of infection

The researchers came to their conclusions after studying over 12,000 adults who participated in the U.S. Centers for Disease Control and Prevention’s National Health and Examination Survey between 2007 and 2012. Those included in the study were asked about their level of alcohol consumption and were given physical examinations that measured levels of nitric oxide in their lungs.

Out of all the participants, the researchers found that 26.9% could be classified as excessive drinkers, defined as an individual who had more than one drink per day on average for women and two drinks per day for men. After controlling for several variables, the test results showed that these individuals exhaled lower levels of nitric oxide than those who did not drink. This correlation was proven to be pervasive; the more that participants reported drinking, the lower their levels of nitric oxide were.

These findings indicate that the likelihood of respiratory infections is much higher for those who drink excessively. Asthma patients need to be especially cautious, the researchers say. Measuring nitric oxide levels for these individuals is extremely common in order to see how well certain medications are working. Afshar and his colleagues believe that consuming alcohol may invalidate or obscure those results, which could lead to improper dosage recommendations.

The full study has been published the journal Chest. 

A new national study has found that teenagers' use of alcohol has declined significantly over the last 20 years. But a second study has found that their grandparents are getting wasted at a much higher rate.

University of Michigan researchers say they are concerned that more teens are using marijuana, but young people are not drinking alcohol or smoking cigarettes nearly as much as in years past. Aside from marijuana, illicit drug use is also on the decline.

"That's still a lot of young people using these dangerous drugs without medical supervision, but the trending is in the right direction," said Lloyd Johnston, the study's principal investigator. "Fewer are risking overdosing as teenagers, and hopefully more will remain abstainers as they pass into their twenties, thereby reducing the number who become casualties in those high-risk years."

Meanwhile, Baby Boomers are not only smoking more weed, as we reported last week, but are consuming more alcohol. Researchers examined self-reported past-month binge alcohol use and alcohol use disorder in adults over 50. They said they found “significant increases” in past-year alcohol use, past-month alcohol use, past-month binge drinking, and alcohol use disorders.

Boomers on a bender

In a demographic breakdown, the study found that men were more likely to binge drink and suffer from alcohol use disorders than women. However, researchers were concerned that binge drinking and alcohol use disorder was also up among women.

“As females age, they tend to experience a larger impact of physiological changes in lean body mass compared to men,” said Dr. Benjamin, a geriatrician and health services researcher at the Center for Drug Use and HIV Research “Thus, they may experience the adverse effects associated with consuming alcohol even in lower amounts.”

The researchers were particularly alarmed by the increase in binge drinking among older women. Not only can it lead to serious health problems, they say it “can also lead to socially embarrassing or regretful behavior.”

While the liquor cabinet will need closer monitoring while the grandparents are home alone, the grandchildren are more likely to behave themselves. In the Michigan study, fewer teens reported using any illegal drug other than marijuana in the prior 12 months than at any time since 1991.

While the rate shows a drop of about one percentage point in each grade in 2016, they reflect a much larger decline over the longer term.

After 23 students were hospitalized for alcohol intoxication at the beginning of the Fall semester, Ramapo College in Mahwah, New Jersey banned all alcoholic energy drinks on campus.

While all brands of alcoholic energy drinks are banned, one brand in particular, Four Loko, was called out by name. 

The drink, which comes in 23.5 oz cans, in flavors like Fruit Punch, Blue Raspberry, and Cranberry Lemonade, is cheap (about $2.50 each) and has an alcohol content of 12%.

Consuming a whole can of Four Loko apparently produces the same effect as drinking three beers, a can of Red Bull, and a shot of espresso.

Ramapo College is not the first school to ban alcoholic energy drinks. And this is not the first time mixing energy drinks with alcohol has caused concern.

In February 2010, ConsumerAffairs.com reported on a 2008 study done by the University of Florida about the negative effects of mixing alcohol and energy drinks.

In a study of college-aged adults exiting bars, patrons who consumed energy drinks mixed with alcohol had three times the risk of leaving a bar highly intoxicated and were four times more likely to intend to drive after drinking than bar patrons who drank alcohol only.

Which is terrifying when the average breath-alcohol concentration reading for those who mixed alcohol and energy drinks was 0.109, well above the legal driving limit of 0.08.

Study co-author Bruce Goldberger, a professor and director of toxicology in the UF College of Medicine said, "There's a very common misconception that if you drink caffeine with an alcoholic beverage the stimulant effect of the caffeine counteracts the depressant effect of the alcohol and that is not true. We know that caffeine aggravates the degree of intoxication, which can lead to risky behaviors."

In August 2007, ConsumerAffairs.com reported on concern over how alcoholic energy drinks are marketed.

Attorneys general from 28 states appealed to the U.S. Alcohol and Tobacco Tax and Trade Bureau (TTB) to crack down on misleading marketing of alcoholic energy drinks, complaining that the ads suggest they are healthy and are aimed at teenagers and young adults, many of whom are below the legal drinking age.

"Non-alcoholic energy drinks are very popular with today's youth," said Oregon Attorney General Hardy Myers. "Beverage companies are unconscionably appealing to young drinkers with claims about the stimulating properties of alcoholic energy drinks. We urge TTB to take action to stop companies from making misleading claims."

While Four Loko is only sold in liquor stores, one wonders who the manufacturers will hope buys it. The cans are brightly colored; the flavors are fruity and sugary.

Unsurprisingly, it's not just college kids falling victim to the drink. High school students in Mahwah, NJ have been caught with cans of Four Loko, too.

It's estimated that between 11 percent and 20 percent of U.S. teens own such merchandise, which includes T-shirts, hats or other items that feature a particular brand of beverage. Theres growing evidence that this specialized type of marketing effectively reaches teenagers and is associated with alcohol use.

Researchers from the Dartmouth Hitchcock Medical Center conducted a telephone survey of a representative sample of 6,522 U.S. adolescents age 10 to 14 years in 2003. The teens reported information about their drinking behaviors and drinking susceptibility. At three follow-up surveys conducted every eight months, participants answered questions about changes in drinking habits and ownership of alcohol-branded merchandise.

The most commonly owned products were clothing and headwear, with followed by a wide array of items that included jewelry, key chains, shot glasses, posters and pens. Most of the brands were beer, including 45 percent that featured the Budweiser label.

Among teens that never drank alcohol, owning alcohol-branded merchandise and susceptibility to drinking were reciprocally related, with each predicting the other during an eight-month period.

People looking to purchase alcoholic energy drinks in Michigan will now have to cross state lines to get their fix.

The Michigan Liquor Control Commission (MLCC) has rescinded the approval of all alcohol-infused energy drinks, like the headline-making Four Loko, in light of several studies regarding the popular drinks, the widespread community concerns aired by substance abuse prevention groups, parent groups and various members of the public, as well as the FDA's decision to further investigate these products.

Four Loko has been making headlines in the last few weeks since being banned from Ramapo College in New Jersey and Central Washington University in Washington state. The fruity malt liquor is being blamed for sending countless kids in both states to hospitals with alcohol poisoning.

These recent events along with other concerns from emergency room doctors quoted throughout the country have prompted Chairperson Nida Samona and Commissioner Patrick Gagliardi to take action.

The Commission believes the packaging is often misleading, and the products themselves can pose problems by directly appealing to a younger customer and encouraging excessive consumption while mixing alcohol with various other chemical and herbal stimulants.

Critics of the drinks say Four Loko is especially targeted at kids because of its colorful packaging, its cheap price (usually about $3 a can) and its high sugar content which appeals to younger palates and masks any taste of alcohol.

A typical alcoholic energy drink is 24 ounces and has a 12 percent alcohol content, compared to a 12 ounce can of beer, which normally has an alcohol content ranging from 4 to 5%. It's almost three to four times the alcohol content of a 12 ounce beer.

"One can, one serving, is enough to get you intoxicated. Alcohol energy drinks cost on average $2 to $5 per can making these products easily accessible and affordable,” said Commissioner Patrick Gagliardi.

The high amounts of caffeine slows the effects of drunkenness, which might explain why kids are drinking several cans of the potent beverage while they party and end up with near-fatal blood alcohol levels.

"The Commission's concern for the health, safety and welfare of Michigan citizens and the fact that there is not enough research to validate that these products are safe for consumption has made me believe that until further research is done by the FDA, they should no longer be on Michigan shelves,” said Samona.

"Alcohol has been recognized as the number one drug problem among youth, and the popularity of alcohol energy drinks is increasing at an alarming rate among college students and underage drinkers.”

One has to wonder if banning drinks like Four Loko won't just make them more appealing. Four Loko appears to be gaining fans on Facebook, not losing them, and die-hard fans are lamenting the recent Michigan ban.

"This sucks!” said one Michigan resident on a Four Loko Facebook fan page, "Places have thirty days to get them off their shelves...so get them while you can!”

Washington State is following in Michigan's recent footsteps and is banning sales of all alcoholic energy drinks, including the much-buzzed-about Four Loko.

Gov. Chris Gregoire joined Washington State Liquor Control Board Chair Sharon Foster on Wednesday to announce an emergency rule that bans the sale of alcoholic energy drinks in Washington state.

"At my request, the board this morning voted to ban this new breed of alcoholic drinks in our state. I applaud its members for their action," Gregoire said. "I was particularly concerned that these drinks tend to target young people. Reports of inexperienced or underage drinkers consuming them in reckless amounts have given us cause for concern."

The emergency rules will be in effect for 120 days, during which time the WSLCB will seek to make the rules permanent.

The vote comes after nine Central Washington University students became dangerously ill after drinking Four Loko.

Law enforcement officers reported the students had blood alcohol levels ranging from 0.12 to 0.35 percent, more than four times the legal limit.

A blood-alcohol concentration of 0.30 percent is considered potentially lethal.

"Quite simply, these drinks are trouble. They contain up to 12 percent alcohol -- more than twice the amount found in most beer," Gregoire said.

"Added to that are large amounts of caffeine, which can mask the effects of alcohol. By taking these drinks off the shelves we are saying 'no' to irresponsible drinking and taking steps to prevent incidents like the one that made these college students so ill."

Foster said the board is acting in the interest of public safety and acting now so alcoholic energy drinks cannot do anymore harm in the state before the Food and Drug Administration can act.

Mixing alcohol with caffeine drinks isn't new, but energy drinks like Four Loko have been recently gaining popularity with underage drinkers because they're cheap, potent, and so sweet they mask the taste of alcohol.

Mixing alcohol with caffeine is also not a good idea. Research suggests that the combination of caffeine and alcohol create a so-called "wide-awake drunk" and may impair a person's ability to judge his or her level of intoxication.

Risky behavior

This can lead to continued consumption of alcohol and risky behaviors such as driving while intoxicated, assaults and other violence.

A University of Florida survey of 800 randomly selected, college-age bar patrons found that those who consumed alcohol and caffeine were more intoxicated than those who only had alcohol, and four times more likely to say they wanted to drive home.

Combining stimulants such as caffeine and depressants such as alcohol is also bad for the body. It can place undue strain on the heart and central nervous system, dehydrate the body and hinder the body's ability to metabolize alcohol.

The combination can also cause a depressed respiratory system and vomiting during sleep when the stimulants wear off.

Critics of Four Loko and other alcoholic energy drinks say the companies appear to target teens and college students, using social networking sites, interactive fan websites and product giveaways at events.

Critics and officials also worry these potentially harmful drinks can easily be confused with their non-alcoholic energy drink counterparts.

Caffeinated alcoholic beverages may be going the way of Joe Camel. The U.S. Food and Drug Administration has warned four companies that make malt liquors containing caffeine that it considers the caffeine to be "an unsafe food additive."

The letters went to four companies: Charge Beverages Corp., New Century Brewing Co. LLC, Phusion Projects LLC (which does business as the Drink Four Brewing Co.), and United Brands.

The caffeinated malt beverages referenced in these warning letters are

• Core High Gravity HG Green

• Core High Gravity HG Orange

• Four Loko

• Joose

• Lemon Lime Core Spiked

• Moonshot  (This product is labeled as "premium beer with caffeine")

• Max

The FDA said the manufacturers have failed to show that the direct addition of caffeine to their malt beverages is "generally recognized as safe" by qualified experts.  Rather, there is evidence that the combinations of caffeine and alcohol in these products pose a public health concern.

"Consumers should avoid these caffeinated alcoholic beverages, which do not meet the FDA's standards for safety," says Joshua M. Sharfstein, M.D., FDA's principal deputy commissioner. 

The agency has given the firms 15 days to respond to the warning letters and then may proceed to court to stop their sale. In addition, other alcoholic beverages containing added caffeine may be subject to agency action in the future if scientific data indicate that the use of caffeine in those products does not meet safety standards.

A troubling mix

The FDA said that the problem with the drinks is that caffeine can mask sensory cues that people may rely on to determine how intoxicated they are. This means that individuals drinking these beverages may consume more alcohol -- and become more intoxicated -- than they realize. 

At the same time, caffeine does not change blood alcohol content levels, and thus does not reduce the risk of harm associated with drinking alcohol. 

Studies suggest that drinking caffeine and alcohol together may lead to hazardous and life-threatening behaviors.  For example, serious concerns are raised about whether the combination of alcohol and caffeine is associated with an increased risk of alcohol-related consequences, including alcohol poisoning, sexual assault, and riding with a driver who is under the influence of alcohol.

Malt versions of premixed alcoholic beverages come in containers holding between 12 and 32 liquid ounces. Some may also contain stimulant ingredients in addition to caffeine.  Their advertised alcohol-by-volume value is as high as 12 percent, compared to standard beer's usual value of 4 to 5 percent.

These alcoholic beverages are available in many states in convenience stores and other outlets. They often come in large, boldly colored cans comparable in size to "tall" cans of beer -- or in containers resembling regular beer bottles.

States approve

Idaho Attorney General Lawrence Wasden called the FDA's action "a significant and necessary step forward in removing these dangerous products from the market."  Wasden was one of several state attorneys general who urged the FDA to take action against the drinks.

As a result of action by the state AGs, MillerCoors and Anheuser-Busch have agreed to stop producing caffeinated alcohol beverages but smaller manufacturers have stepped in to fill the gap, producing drinks with alcohol contents as high as 12 percent. 

Four Loko was blamed for the hospitalization of 23 students at Ramapo College in New Jersey and to the hospitalization of nine students after a party Central Washington University.  Both incidents happened in October and the drink was subsequently banned from both campuses.

The Michigan Liquor Control Commission banned all alcohol-infused energy drinks earlier this month.

Thorough investigation

FDA's action follows an examination of the published peer-reviewed literature on the co-consumption of caffeine and alcohol, consultation with experts in the fields of toxicology, neuropharmacology, emergency medicine, and epidemiology, and a review of information provided by product manufacturers. FDA also performed its own independent laboratory analysis of these products.

"FDA does not find support for the claim that the addition of caffeine to these alcoholic beverages is 'generally recognized as safe,' which is the legal standard," said Dr. Joshua M. Sharfstein, Principal Deputy Commissioner. "To the contrary, there is evidence that the combinations of caffeine and alcohol in these products pose a public health concern."

Dangerous drinks

Experts have raised concerns that caffeine can mask some of the sensory cues individuals might normally rely on to determine their level of intoxication. The FDA said peer-reviewed studies suggest that the consumption of beverages containing added caffeine and alcohol is associated with risky behaviors that may lead to hazardous and life-threatening situations.

The agency said the products named in the warning letters are being marketed in violation of the Federal Food, Drug, and Cosmetic Act (FFDCA). Each warning letter requests that the recipient inform the FDA in writing within 15 days of the specific steps that will be taken to remedy the violation and prevent its recurrence.

If a company does not believe its products are in violation of the FFDCA, it may present its reasoning and any supporting information as well.

If the FDA believes that the violation continues to exist, the agency may pursue an enforcement action that could include seizure of the products or an injunction to prevent the firm from continuing to produce the product until the violation has been corrected.

The agency's action follows a November 2009 request to manufacturers to provide information on the safety of adding caffeine to their products.

Positive step

FDA says it is aware that on November 16, Phusion Projects, LLC -- the maker of Four Loko -- announced its intention to remove caffeine and other stimulants from its drinks, and calls the announcement "a positive step."

But the agency notes that it has not yet heard officially from the company about this announcement, including how quickly it will remove present product from circulation and how quickly it will reformulate its product.

Says it will work with Phusion the other manufacturers to assure their products meet safety standards.

---

This story includes reporting by James Limbach.

With the growing popularity of energy drinks such as Red Bull, Monster, Burn and RockStar, especially among high school and college students, psychologists have been studying the effects of sugary, highly caffeinated drinks on young people.

College students in particular have been using these drinks to stay awake, help them study and cut the intoxicating effects of alcohol.

The latter use has sent dozens of young people to hospital emergency rooms, leading a handful of state liquor control boards recently to ban the drink Four Loko, which combined caffeine and alcohol.

"Several aspects of cognitive performance that show improvement under the influence of caffeine are attention, reaction time, visual search, psychomotor speed, memory, vigilance and verbal reasoning," said Cecile A. Marczinski, PhD, of Northern Kentucky University and co-author of the study "Acute Effects of a Glucose Energy Drink on Behavioral Control."

"The results of the current study illustrate that energy drinks can increase stimulation and decrease mental fatigue, suggesting that they may be used with alcohol to counteract the sedation associated with drinking."

The study, published in the December issue of the APA journal Experimental and Clinical Psychopharmacology, included 80 college students (34 men and 46 women) between the ages of 18 and 40.

Some were given Red Bull 7, while others were given lower amounts of caffeine added to Squirt, a lemon-flavored decaffeinated soda that looks and tastes like Red Bull. Others were given plain Squirt as a placebo.

A half hour after finishing the drinks, participants took a computerized test in which they had to respond quickly to targets on a screen.

Participants were also asked how stimulated and mentally fatigued they felt after the drinks.

The students who were given Red Bull reported feeling more stimulated and less tired than the other participants, but their response rates were slower.

"This finding is of interest given that energy drinks are frequently mixed with alcohol and the acute effects of alcohol impair response inhibition," Marczinski said.

"Since regulation of energy drinks is lax in the United States in regard to content labeling and possible health warnings, especially mixed with alcohol, having a better understanding of the acute subjective and objective effects of these beverages is warranted."

In a second study reported in the same journal, Jennifer L. Temple, PhD, and colleagues at the University at Buffalo found boys and girls respond differently physiologically to caffeine.

In this experiment, 26 boys and 26 girls between the ages of 12 and 17 drank flattened Sprite containing caffeine at three concentrations: 50 mg, 100 mg or 200 mg. Flat Sprite with no caffeine was included as a placebo.

The youngsters were then tested for changes in their blood pressure and heart rate every 10 minutes for one hour.

At the end of the hour, they were given a questionnaire and an opportunity to eat all they wanted of different types of junk food: Skittles and Smarties (high sugar/low fat); potato chips and Doritos (low sugar/high fat); and M&Ms and Twix (high sugar/high fat).

Among boys, high caffeine consumers showed greater increases in their diastolic blood pressure than boys who ingested less caffeine. There was no relationship between blood pressure and caffeine consumption in girls.

In addition, those participants who ingested the most caffeine ate more high-sugar snack foods in the laboratory compared to low-caffeine consumers.

Boys and girls also had different reasons for consuming caffeine, the researchers found.

Boys were more likely than girls to say they consumed caffeine "to get energy," "to get a rush," and for "athletic performance."

"Adolescents are among the fastest growing consumers of caffeine and yet very few empirical studies have focused on this population," Temple said. "It is imperative that we understand the impact of caffeine use on adolescents."

Even though controversy has died down over Four Loko and other highly-caffeinated alcoholic beverages, it appears health officials still have a wary eye trained on energy drinks.

Love Red Bull? You might want to stock up now.

According to researchers at the University of Maryland School of Public Health and Wake Forest University School of Medicine, highly-caffeinated energy drinks -- even those containing no alcohol -- may pose a significant threat to individuals and public health.

In a new online commentary in the Journal of the American Medical Association (JAMA), they recommend immediate consumer action, education by health providers, voluntary disclosures by manufacturers and new federal labeling requirements.

“Recent action to make pre-mixed alcoholic energy drinks unavailable was an important first step, but more continued action is needed,” says University of Maryland School of Public Health researcher Amelia Arria.

“Individuals can still mix these highly caffeinated energy drinks with alcohol on their own. It is also concerning that no regulation exists with regard to the level of caffeine that can be in an energy drink.”

Arria, who also directs the Center on Young Adult Health and Development, and co-author Mary Claire O’Brien, associate professor of emergency medicine at Wake Forest University School of Medicine, alerted various state attorneys general to the risks of alcoholic energy drinks starting in 2009.

These actions culminated last November in actions against Four Loko and similar products by the U.S. Food and Drug Administration and the Federal Trade Commission.

HEALTH RISKS

The JAMA paper cites three public health concerns surrounding all packaged energy drinks containing moderate to high levels of caffeine:

Consumers often mix alcohol and energy drinks: “Energy drinks have become enmeshed in the subculture of partying,” the paper says.

“The practice of mixing energy drinks with alcohol -- which is more widespread than generally recognized -- has been linked consistently to drinking high volumes of alcohol per drinking session and subsequent serious alcohol-related consequences such as sexual assault and driving while intoxicated… Research has demonstrated that individuals who combine energy drinks with alcohol underestimate their true level of impairment.”

Caffeine can have adverse health effects in susceptible individuals: “Therefore continued public health awareness regarding high levels of caffeine consumption, no matter what the beverage source, in sensitive individuals is certainly warranted,” the researchers write.

Energy drink use appears to be associated with alcohol dependence and other drug use: More research is needed to clarify the possible mechanisms underlying the associations that have been observed in research studies.

The researchers recommend several “proactive steps to protect public health:”

• Health care professions should inform their patients of the risks of consuming highly caffeinated energy drinks;
• Individuals should educate themselves about those risks;
• Manufacturers should warn consumers about the risks of mixing their products with alcohol;
• Regulatory agencies should require energy drink manufacturers to disclose caffeine content on product labels and display appropriate warnings.

The attorneys general of 24 states are asking the Federal Trade Commission (FTC) to take stronger measures to stop underage drinking. In a letter to the FTC, the attorneys general offered a three-step plan to keep alcohol advertising away from teens.

“The more young people are exposed to alcohol advertising and marketing, the more likely they are to drink, or if already drinking, to drink more,” wrote Utah Attorney General Mark Shurtleff and the other attorneys general.

The FTC is planning to collect information from advertisers about the way alcohol is advertised, sold and marketed and how data is collected. The attorneys general offered three ways this should be done:

1. Advertising and promotional spending data should be collected on an ongoing basis instead of intermittently.

2. Alcohol advertising should not be allowed when more than15% of the people in the audience are between the ages of 12 and 20.

3. Alcohol advertising data should include digital and social media marketing such as blogs and corporate sponsored social media sites.

On May 8, 2006, the attorneys general sent a letter endorsing the FTC’s proposal to set the standard that alcohol advertising be directed to audiences where at least 70% of the audience is of legal drinking age. A higher standard is now being proposed to limit the amount of advertising to those between the ages of 12 and 20 year old, which is 15%, rather than the percentage of those under 21, which is 30%.

“With the health and lives of this nation’s young people at stake, we believe that state, federal and industry efforts are needed to stem the flow of alcohol to our youth,” concludes the attorneys general.

The letter was signed by the attorneys general in Arizona, Connecticut, Delaware, Guam, Hawaii, Idaho, Illinois, Iowa, Maryland, Massachusetts, Mississippi, Nevada, New Hampshire, New Mexico, New York, Oklahoma, Oregon, Rhode Island, South Carolina, Tennessee, Utah, Vermont, Washington and Wyoming. 

The marketers of Four Loko have agreed to re-label and repackage the supersized, high-alcohol, fruit-flavored, carbonated malt beverage, to resolve Federal Trade Commission charges of deceptive advertising.

“Deception about alcohol content is dangerous to consumers, and it’s a serious concern for the FTC,” said David Vladeck, Director of the agency’s Bureau of Consumer Protection.  “Four Loko contains as much alcohol as four or five beers, but it is marketed as a single-serving beverage.”

The FTC alleges that Phusion Projects, LLC and its principals falsely claimed that a 23.5-ounce, 11 or 12 percent alcohol by volume can of Four Loko contains alcohol equivalent to one or two regular 12-ounce beers, and that a consumer could drink one can safely in its entirety on a single occasion.

In fact, according to the FTC, one can of Four Loko contains as much alcohol as four to five 12-ounce cans of regular beer and is not safe to drink on a single occasion.  Consuming a single can of Four Loko on a single occasion constitutes “binge drinking,” which is defined by health officials as men drinking five (and women drinking four) or more standard alcoholic drinks in about two hours.

Drinking from the can

The 23.5-ounce Four Loko cans are the size of about two regular beer cans and are non-resealable. The FTC complaint alleged that on one company website, consumers were encouraged to enter a “photo contest” in which they posted many photos of people drinking directly from the 23.5-ounce Four Loko cans. In stocking instructions, Phusion urged merchants to place the cans where other refrigerated, single-serve alcoholic beverages are displayed.

The administrative settlement requires Phusion Projects to include disclosures on containers of Four Loko, or any other flavored malt beverage containing more  alcohol than two and-a-half regular beers, stating how much alcohol – compared to the amount of alcohol found in regular beer – is in the drink.  The order also specifies the location and appearance of the disclosure.  For example, the disclosure for a 23.5 ounce can of Four Loko with 12 percent alcohol by volume would state:  “This can has as much alcohol as 4.5 regular (12 oz. 5% alc/vol) beers.”

Starting six months after the settlement takes effect, Phusion Projects is required to use only resealable containers for flavored malt beverages that have more alcohol than the equivalent of two and a half regular beers.

Also, the settlement bars Phusion Projects from misrepresenting the alcohol content of any beverage, and from depicting people drinking directly from the container of any product containing more alcohol than that found in two and a half regular beers.

It's illegal to sell alcoholic beverages to anyone under 21 years of age, but a new study concludes that hasn't stopped the industry from marketing to underage consumers.

The Center on Alcohol Marketing and Youth (CAMY) at the Johns Hopkins Bloomberg School of Public Health has documented what it says is the alcohol industry’s push into digital marketing. The findings, the center says, raise questions whether the industry’s self-regulation is adequately protecting underage youth from exposure to the “alcohol experience” available on social marketing platforms such as FaceBook, YouTube and Twitter.

CAMY, in turn, has used the Internet to fight back, releasing its findings in a series of YouTube videos.

Large Facebook presence

The study found that 10 leading alcohol brands have more than 16.5 million people "liking" their Facebook brand pages, and as of November 2011, 10 alcohol brands with youth appeal had uploaded 35,725 photos and 377 videos to their Facebook pages. Fans of brands with youth appeal had also uploaded 15,416 photos and 98 videos to the brand Facebook pages, taking their messages viral.

Images of Santa, toys, and sexually suggestive photos as well as those indicating binge consumption of alcohol are on the industry’s social media sites despite the industry standards, the center said.

CAMY said it also tested the adequacy of the industry’s “age affirmation” technology that is aimed at preventing exposure of this marketing to underage youth. The result? "Essentially meaningless," the center said. “Age affirmation” means a social media site user needs to state their age, but the age is not verified.

Number one problem

CAMY says alcohol is the number one drug problem among American youth. Each year, an estimated 4,700 youth die from excessive alcohol use. More young people drink alcohol than smoke tobacco or use marijuana, though a recent survey suggested the number of teens drinking alcohol is declining while the number smoking marijuana is climbing.

In 2003, trade groups for beer and distilled spirits committed to placing alcohol ads in media venues only when underage youth comprises less than or equal to 30 percent of the audience. At least 14 longitudinal scientific studies have found that the more young people are exposed to alcohol marketing, the more likely they are to start drinking or, if already drinking, to drink more.

“Over and over again, youth are more likely to hear, read or see alcohol ads in mainstream media, and brands are now taking their messages from their branded sites to social media platforms such as YouTube, Flickr, Twitter, and Facebook,” said David Jernigan, director of the Center on Alcohol Marketing and Youth. “As teens are early adopters of social media and there are viral elements of this media, parents need to be more aware of this marketing and to educate their children about the real harms of underage drinking in spite of the industry’s message of glamour and allure.”

Many of the advertisements for beer, wine and spirits these days carry the tag line “drink responsibly.” But an anti-alcohol advocacy has gone on the attack, saying the disclaimer does nothing to reduce the overconsumption of alcohol.

"Alcohol producers and marketers are more interested in their public relations than public health," said Sarah Mart, director of research at the group Alcohol Justice. "So it's not surprising that they hide behind a vague, ineffective slogan that does nothing to reduce the annual catastrophe of harm caused by their products."

The group takes particular exception when alcoholic beverage marketers work their brand name into the slogam as in "Enjoy Heineken Responsibly" or "The perfect way to enjoy Patron is responsibly."

Alcohol Justice said it reviewed "drink responsibly" messages in print ads in the September/October 2011 issues of forty-one different magazines that enjoy a high proportion of youth readership. They analyzed frequency, location, size, and content of beer, spirits and alcopops brand ads found in those publications, and compared the size of "drink responsibly" messages, if present, in the ads. Ninety-four percent of the ads, the group says, contained "drink responsibly" messages.

Promoting brands

"We found numerous problems with the "drink responsibly" messages in our review," said Mart. "Messages blended into backgrounds so that they virtually disappeared, or were tiny in relation to the size of the entire ads. But the most obvious problem was that companies use the message to promote brands, loyalty, and drinking."

The group said it is asking the state attorneys general to investigate the industry's “drink responsibly” messages as “misleading and deceptive advertising.”

The group advocates restricting advertising and raising taxes on alcoholic beverages as a way to discourage over-consumption.

Alcoholic beverage makers have, indeed, embraced responsible drinking in the last decade. All major brands have campaigns to that effect. But they aren't the only ones. The U.S. Marine Corps also has a “drink responsibly” campaign.

“The unit leaders aboard MCAS Iwakuni are focused on eliminating alcohol abuse and decreasing the number of alcohol-related incidents,” the Marines say on their website. “Combating the debilitating threat posed by alcohol abuse and alcohol dependency on Marines, sailors, and mission readiness requires a total commitment from all levels of leadership. Leaders must be alert to characteristics of alcohol abuse and with the symptoms of the disease of alcohol dependency. All leaders must not in any way promote or condone alcohol misuse.”

The Corps notes that alcohol is closely associated with violence, with about 40 percent of all crimes committed under the influence of alcohol.

Rules controlling alcohol sales over the Internet have been tightened in recent years to prevent sales to minors. The Center on Alcohol Marketing and Youth (CAMY) says they are still aren't tough enough.

The group cites a new report from authors Rebecca Williams and Kurt Ribisl at the University of North Carolina that documents the relative ease with which underage youth can purchase alcohol online.

To prove their point, Williams and Ribisl had underage teens try to purchase alcohol online from a number of different sites. They were successful in 45 out of 100 attempts.

“The fact that there are literally thousands of online outlets selling alcohol and that purchase attempts by underage persons are successful almost half of the time tells us how insufficient the protections are for our youth,” said David Jernigan, PhD, director of CAMY.

Number one drug

The group says alcohol is the number one drug for young people, and is responsible for 4,700 deaths per year among young people under the age of 21 in the U.S.

Jernigan also noted that the Internet “marketplace” for alcohol goes beyond the sites selling alcohol and includes the industry’s advertising and marketing efforts.

For example, a 2011 CAMY report documented the extent to which alcohol marketers are using Facebook and therefore reaching underage youth with advertisements and other content. CAMY researchers found that the 10 leading alcohol brands have almost 6.7 million people “liking” their Facebook pages.

CAMY says least 14 studies have found that the more young people are exposed to alcohol advertising and marketing, the more likely they are to drink, or if they are already drinking, to drink more.

“The bottom line is that alcohol regulation and enforcement are simply not keeping up with new technologies,” said Jernigan. “Tighter controls on content and better technology to limit underage access are needed to reduce alcohol use among young people.”

Alcohol marketers have to deal with all kinds of regulations set by the Federal Trade Commission (FTC), so they don't promote products to under-aged consumers. But that hasn't stopped social networking sites like Facebook from linking up with major alcohol brands like Anheuser-Busch and Heineken.

But Twitter, which hasn't yet been heavily associated with beer, wine or liquor promotions, is looking to catch up to Facebook by implementing an age-checking component, that products like Coors Light have already tested and started using.

The reason Facebook has a jump on Twitter in the area of alcohol promotions, is because users have to enter their date of birth to sign up for the social site. However, anyone can create a Twitter account without age verification, which has made it nearly impossible to gauge what age each follower really is.

However, as Mark Huffman reported earlier today, critics say the Facebook system is faulty and consumer complaints are ignored.

“There are underage children on Facebook, even posting their age and country,” John of Brisbane, Australia, wrote in a ConsumerAffairs posting. “I have tried to report it so it can be fixed but just get ignored.”

Facebook, meanwhile, is said to be considering letting kids under 13 sign up for its site, which isn't expected to go over well with parents and child safety advocates.

Both Twitter and social media experts Buddy Media have created a new age verifier, in hopes that any alcohol that's marketed, will only be viewed by age-appropriate followers.

"For now, we are testing this solution with a small group of advertisers. We will determine next steps after the conclusion of these tests," Twitter said in a statement.

May not be enough

But simply adding an age verifier on social network pages, may not be enough to mollify the Federal Trade Commission, as the government agency continues to examine the data collection of social media pages.

"We believe it is time to launch a new major study to measure current compliance with the self-regulatory standards, to look into new developments in alcohol marketing and to determine what additional recommendations, if any, are warranted," said Janet Evans, senior attorney at the Federal Trade Commission, in a 2011 Ad Age interview.

Overall, the FTC found that 92 percent of radio, TV and print ads successfully complied with regulations of having to promote in areas were 70 percent of the audience is over 21. Digital Media companies also had to promote in online areas, where 70 percent of the users were 21 years or older. According to ComScore, 78.7 percent of Twitter users are at least 21 years of age.

The way Twitter chooses to verify age is by having the user provide their date of birth if they want to follow an alchohol product. Once a user decides to click on a brand, they have to complete a form within a 24-hour period, until they're able to permanently follow that alcohol brand.

So far the new age verifier has allowed major alcohol brands to partner with Twitter with apparent confidence that the FTC will not come and halt its advertising. Heineken, Dos Equis, the liquor company Beam, and Courvoisier have all decided to take a chance and market their products via Twitter.

Andrea Javor, Senior Manager of Beam's digital media division, said the company saw 60 percent of its social media presence come from Twitter, while only 30 percent came from Facebook. 

Does it work?

But, critics of both Twitter and Facebook's alcohol marketing believe the system in place can't truly verify a persons age, as users can enter any date of birth they want. However, Facebook spokesperson Annie Ta took extreme exception to this reasoning.

"We take the issue of underage drinking seriously," she said. "We require that all alcohol-related advertisements use our tools and demographic targeting options to restrict the ad to users who are over the legal drinking age" and "we strictly enforce this policy through proactive investigations and response to user reports. We also require developers to restrict access to alcohol-focused applications, and respond to all reports of breaches in this policy."

A representative of Twitter had a similar response: "We are trusting users to input their valid birth date, and we have no plans to cross reference this with third-party data."

The Center for Science in the Public Interest has filed suit against MillerCoors Brewing Company, formerly Miller, over its alcoholic energy drink, Sparks.

The product has more alcohol than regular beer and contains unapproved additives, including the stimulants caffeine and guarana, according to the lawsuit, which is asking the Superior Court of the District of Columbia to stop MillerCoors from selling the controversial drink, which is also under scrutiny from state attorneys general.

Drinkers of caffeinated alcoholic drinks are more likely to binge drink, ride with an intoxicated driver, become injured, or be taken advantage of sexually than drinkers of non-caffeinated alcoholic drinks, according to a 2007 study conducted at Wake Forest University.

CSPI says Sparks contain 6 to 7 percent alcohol by volume, as opposed to regular beer, which typically has 4 or 5 percent alcohol. Also unlike beer, Sparks' appeal to young people is enhanced by its sweet citrusy taste, much like SweeTarts candy, and the bright color of orange soda. Sparks Light also contains the artificial sweetener sucralose. In October, CSPI says MillerCoors plans to release Sparks Red, which will have 8 percent alcohol by volume.

"MillerCoors is trying to hook teens and 'tweens on a dangerous drink," said CSPI litigation director Steve Gardner. "This company's behavior is reckless, predatory, and in the final analysis, likely to disgust a judge or a jury."

Sparks' juvenile web site and guerilla marketing appeal to young consumers, according to CSPI. The web site offers a recipe for a drink called a "Lunchbox," consisting of half Miller beer and half Sparks, and elsewhere, the site proposes consuming Sparks for breakfast alongside omelets.

The company also hosts give-aways of Sparks at house parties, sponsors events unrelated to beer such as art shows, and engages in other unconventional marketing practices, according to the Milwaukee Journal Sentinel.

CSPI's court filing notes that private gatherings such as house parties do not have the same licensing or other safeguards as public establishments that prevent minors from accessing alcohol.

"Mix alcohol and stimulants with a young person's sense of invincibility and you have a recipe for disaster," said George A. Hacker, director of CSPI's alcohol policies project. "Sparks is a drink designed to mask feelings of drunkenness and to encourage people to keep drinking past the point at which they otherwise would have stopped. The end result is more drunk driving, more injuries, and more sexual assaults."

According to a 2006 study, the stimulants in these products do not reduce alcohol's negative effects on motor skills and reaction times but do impair people's perception of intoxication. As a result, drinkers may engage in risky behavior, such as driving, because they feel less drunk but in reality are too intoxicated to get behind wheel.

CSPI's lawsuit also contends that it is illegal to use caffeine, guarana, ginseng, and taurine in alcoholic beverages. The federal agency with primary responsibility for regulating alcoholic beverages, the Treasury Department's Tax and Trade Bureau, says alcoholic beverages may contain only ingredients considered General Recognized as Safe, or GRAS, by the Food and Drug Administration.

But the FDA has given only very narrow approval for caffeine and guarana -- with no allowance for alcoholic drinks -- and no approval for ginseng in any food or beverage. Taurine is approved only for use in chicken feed, not human food.

In February, CSPI notified Anheuser-Busch and Miller of its intent to sue both companies over caffeinated alcoholic drinks. In June, Anheuser-Busch entered into separate agreements with CSPI and 11 state attorneys general in which the brewer agreed to take caffeine and other unapproved additives out of its two alcoholic energy drinks, Bud Extra and Tilt.

Anheuser-Busch paid the 11 states $200,000 to reimburse them for the cost of the investigation and called on other brewers and distillers not to market pre-packaged caffeinated alcoholic drinks.

Anheuser-Busch's recent decision at the prodding of eleven state attorneys general to discontinue its two energy drinks, Tilt and Bud Extra, has won nods of approval from health care professionals.

But despite Busch's action, there are an estimated 200 energy drinks still on the market. That's a lot of energy.

"There was a time when we would get our caffeine intake from coffee and cola, but now there are a number of caffeine containing beverages and we need to be careful because over a period of 24 hours that caffeine intake is cumulative," said Dee Rollins, R.D., PhD, dietitian with Baylor Regional Medical Center at Grapevine, Texas.

In fact, experts say energy drink consumers should keep careful track of the amount of caffeine they get in a day.

"If you know that 400 milligrams a day is the upper limit you can check the back of the labels and make sure that you don't get more than that," Rollins said.

It may sound like a lot, but 400 milligrams is roughly the equivalent of just one energy drink and two cups of coffee. Getting more than that can lead to jitteriness, nausea, heart palpations and in extreme cases more severe symptoms.

"It can be so bad that if you take too much caffeine you can end up in the hospital thinking you have flu-like symptoms and really it's caffeine overdose."

So remember as you're sipping take it slow or it may not just be energy you end up with.

"We don't think of caffeine as being a drug that we need to monitor, but we can overdo it," Rollins said.

For most people if they're not getting more than around 400 milligrams of caffeine a day these energy drinks are safe. But Rollins says there are some important things to remember:

• Don't drink energy beverages while exercising. It can lead to severe dehydration.

• Don't ever mix these drinks with alcoholit's popularbut doing so can not only mask how intoxicated you really are, it again can be extremely dehydrating.

In addition to caffeine, most of these energy drinks contain very high amounts of sugar and sodium which can be dangerous for diabetics or those with high blood pressure, Rollins said.

Under fire from the attorneys general of 11 states, Anheuser-Busch has agreed to discontinue its popular alcoholic energy drinks, including Tilt and Bud Extra, and vowed it will not produce any caffeinated alcohol beverages in the future.

Anheuser-Busch, the largest brewing company in the United States, has taken an important action to protect young people from attractive alcohol advertising and marketing, California Attorney General Edmund G. Brown Jr. said. Other major alcohol manufacturers should follow Anheuser-Buschs lead and eliminate dangerous combinations of caffeine and alcohol from the marketplace.

Alcoholic energy drinks are prepackaged beverages that combine alcohol and caffeine, guarana, taurine, ginseng and other ingredients associated with non-alcoholic energy drinks. Brown asserts that Anheuser-Busch marketed Bud Extra and Tilt in violation of state consumer protection statues by:

• Making misleading health-related statements about allegedly energizing effects of Bud Extra including increased strength and increased ability to stay up all night after drinking the products

• Failing to disclose its effects on consumers, and ignoring potential consequences of drinking alcoholic beverages that are combined with caffeine or other stimulants

• Directing advertisements of Tilt and Bud Extra to consumers under the age of 21

In November 2007, researchers at Wake Forest University of Medicine found that the combination of caffeine and alcohol sends mixed signals to the nervous system, causing the effect of a wide awake drunk.

Students who consumed these energy drink cocktails were twice as likely to be involved in alcohol-related accidents and injuries than when drinking alcohol alone. The combination of alcohol and caffeine can be dangerous because individuals may not feel impaired even when blood alcohol levels are very high.

California, along with ten other states, asserted that Anheuser-Busch made misleading health-related statements about the energizing effects of its caffeinated alcohol beverages. Marketing that promoted the alleged energy component of the drinks made the drinks appealing to teens.

The company advertised Bud Extra with taglines such as You can sleep when youre 30 and Say hello to a night of fun and utilized MySpace, YouTube, and other Internet sites popular with underage youth.

In addition, the packaging for many of the alcoholic energy drinks was similar to that for non-alcoholic energy drinks, leading to retailer and parent confusion.

Anheuser-Busch cooperated during the investigation and agreed to reformulate its products to exclude caffeine. As part of the agreement, Anheuser-Busch will discontinue two of its popular alcoholic energy drinks, Tilt and Bud Extra, and will not produce any caffeinated alcohol beverages in the future. Under the agreement the company will:

• Stop manufacturing and marketing all caffeinated alcoholic beverages, including Bud Extra and Tilt as currently formulated

• Reformulate its alcoholic energy drinks so that they do not contain caffeine or other stimulants that are metabolized as caffeine, such as Guarana

• Eliminate all references in advertising to caffeinated formulations and remove any reference to using Bud Extra and Tilt as mixers for other drinks.

Anheuser-Busch also agrees to immediately discontinue the current Tilt website www.tiltthenight.com without hyper linking or directing visitors to a new site. Any new Website may only to promote the reformulated Tilt without caffeine.

Other states which joined California in reaching an agreement with Anheuser-Busch include: Arizona, Conneticut, Idaho, Illinois, Iowa, Maine, Maryland, New Mexico, New York and Ohio. A copy of the multi-state agreement is attached.

Energy drinks are emerging as a beverage of choice for young people, who often mix them with alcohol. But combining alcohol and energy drinks may create a dangerous mix, according to research conducted at the University of Florida.

In a study of college-aged adults exiting bars, patrons who consumed energy drinks mixed with alcohol had three time the risk of leaving a bar highly intoxicated and were four times more likely to intend to drive after drinking than bar patrons who drank alcohol only.

The study appears in the April issue of the journal Addictive Behaviors.

"Previous laboratory research suggests that when caffeine is mixed with alcohol it overcomes the sedating effects of alcohol and people may perceive that they are less intoxicated than they really are," said the study's lead researcher Dennis Thombs, an associate professor in the UF College of Public Health and Health Professions' department of behavioral science and community health. "This may lead people to drink more or make uninformed judgments about whether they are safe to drive."

The UF study is the first of its kind to evaluate the effects of alcohol mixed with energy drinks in an actual drinking environment, that is, at night outside bars. Research on college student alcohol use in campus communities has traditionally relied on self-report questionnaires administered to sober students in daytime settings, Thombs said.

Data for the UF study were collected in 2008 from more than 800 randomly selected patrons exiting establishments in a college bar district between the hours of 10 p.m. and 3 a.m. Researchers conducted face-to-face interviews with participants to gather demographic information and details on participants' energy drink consumption and drinking behavior.

Participants also completed self-administered questionnaires that asked about their drinking history and intention to drive that night. Next, researchers tested participants' breath alcohol concentration levels. Participants received feedback on their intoxication levels and advice about driving risk.

3 times more likely to be drunk

Bar patrons who reported drinking alcohol mixed with energy drinks -- 6.5 percent of study participants -- were three times more likely to be intoxicated than drinkers who consumed alcohol only. The average breath-alcohol concentration reading for those who mixed alcohol and energy drinks was 0.109, well above the legal driving limit of 0.08.

Consumers of energy drink cocktails also left bars later at night, drank for longer periods of time, ingested more grams of ethanol and were four times more likely to express an intention to drive within the hour than patrons who drank alcohol only.

Consumers of alcohol mixed with energy drinks may drink more and misjudge their capabilities because caffeine diminishes the sleepy feeling most people experience as they become intoxicated. It's a condition commonly described as "wide awake and drunk," said study co-author Bruce Goldberger, a professor and director of toxicology in the UF College of Medicine.

"There's a very common misconception that if you drink caffeine with an alcoholic beverage the stimulant effect of the caffeine counteracts the depressant effect of the alcohol and that is not true," Goldberger said. "We know that caffeine aggravates the degree of intoxication, which can lead to risky behaviors."

The study, funded by the University of Florida Office of the President, raises a lot of questions and suggests topics for future research, Thombs said.

"This study demonstrates that there definitely is reason for concern and more research is needed," he said. "We don't know what self-administered caffeine levels bar patrons are reaching, what are safe and unsafe levels of caffeine and what regulations or policies should be implemented to better protect bar patrons or consumers in general."

The CDC study, published in the January 2007 issue of Pediatrics, found that 45 percent of the teenagers responding to a survey reported consuming alcohol in the past month, and 64 percent of the students who drank said they were binge drinking, which is defined as having five or more alcoholic drinks in a row.

The CDC report also found that binge drinking is strongly associated with sexual activity, violence, and other risky behaviors.

"Contrary to popular belief, parents remain the greatest influence over their children's behavior," said Richard Gallagher, Ph.D., Director of the Parenting Institute and the Thriving Teens Project at the NYU Child Study Center.

"Though media and peers play a role, parental influence is critical and there are ways parents can maximize that influence to reduce the likelihood that their children will engage in binge drinking," he said.

Dr. Gallagher offers these tips for parents:

• Clearly state what actions you expect your teen to take when confronted with substance use. Teens who know what their parents expect from them are much less likely to use substances, including alcohol.

• Talk about the alcohol use that your children observe. Parents need to make it clear how they want their children to handle substances, such as alcohol and tobacco. Children need to have controlled exposure to learn the rules of acceptable use.

• Help your teen find leisure activities and places for leisure activities that are substance-free. Then, keep track of where, with whom, and what your teen is doing after school and during other free times.

• Limit the access your children have to substances. Teens use substances that are available. They report that they sneak alcohol from home stocks, take cigarettes from relatives, and obtain marijuana from people that they know well.

• Inform teens about the honest dangers that are associated with alcohol use and abuse. Although teens are not highly influenced by such information, some discussion of negative consequences has some impact on the decisions they make. Especially emphasize how alcohol clouds one's judgment and makes one more likely to be harmed in other ways.

For more information on teenage substance use and abuse, visit www.AboutOurKids.org.

The report marks the first time the annual National Survey on Drug Use and Health asked detailed questions about the behavior and social situations involved in underage drinking.

"In far too many instances parents directly enable their children's underage drinking -- in essence encouraging them to risk their health and well-being. Proper parental guidance alone may not be the complete solution to this devastating public health problem -- but it is a critical part," said Acting Surgeon General Steven K. Galson, M.D., M.P.H. in releasing the report.

Some of the key findings include:

• Ninety percent of underage drinkers were either given alcohol for free or had someone else purchase it for them.

• Eighty-four percent (84%) of underage drinkers were in their own home or someone else's home when they had their last drink; 9.4 percent were at a restaurant, bar or club.

• Among all underage current drinkers, 31 percent paid for the alcohol the last time they drank, including 21.6 percent who gave money to someone else to purchase the alcohol and 9.3 percent who purchased the alcohol themselves. The remaining 69 percent of underage drinkers did not pay for the alcohol on their last drinking occasion.

• Of the 9.3 percent of underage individuals who purchased alcohol for themselves, 5.2 percent of individuals bought it at a liquor, convenience or grocery store and 2.8 percent bought it at a restaurant, bar or club.

• Over 40 percent of underage drinkers received alcohol for free from adults over 21 including 25.8 percent who were given alcohol by an unrelated person aged 21 or older, 6.4 percent who were given alcohol by their parent or guardian, and 8.3 percent who were given alcohol by another family member aged 21 or older.

• Past month alcohol use dropped 11 percent (from 7.4 percent in 2002 to 6.6 percent in 2006) for youth aged 12 to 14; declined 8 percent (from 28.3 percent in 2002 to 26.1 percent in 2006) for youth aged 15 to 17; and remained flat at around 51 percent for 18 to 20 year olds in the same time period.

Distilled Spirits Council President Peter Cressy said that this study's findings on sources of youth alcohol access are mirrored by research by the National Academy of Sciences and the Federal Trade Commission, which both found that youth primarily obtain alcohol from social sources including parents or adult family members and friends.

"While parents may believe they have no impact on their teens' behavior, this study once again underscores that parental involvement is key to the decisions underage make about drinking or not drinking," said Cressy. "Our country is making important progress in preventing and reducing underage drinking but much more needs to be done. Parents and the entire community working together can make a difference."

Seventy-one percent of Americans support a five cent per drink increase in federal alcohol taxes, according to new survey research commissioned by the nonprofit Center for Science in the Public Interest (CSPI).

As lawmakers consider slashing popular social programs to bridge the federal budget gap, CSPI says they should instead consider raising taxes on beer, wine, and spirits -- which could raise more than $20 billion in desperately needed revenue over the next five years.

When asked whether they prefer raising alcohol taxes or cutting social programs as a way of offsetting the budget deficit, a whopping 79 percent of respondents favor the alcohol tax increase. Even 68 percent of Republicans surveyed and 70 percent of drinkers would support raising alcohol taxes over cutting programs such as food stamps, Medicaid, and drug benefits for the elderly.

"Raising alcohol taxes alone may not balance the budget, but it would boost revenues in a way that's popular, fair, and provides real money," said George A. Hacker, director of CSPI's alcohol policies project.

"In past decades, alcohol interests have too often beaten back any across-the-board increases in booze taxes. But with an expensive war being waged, and with painful cuts in popular social programs on the table, we can't let one politically powerful industry keep evading its fair share," Hacker added.

In recent decades, federal taxes on alcoholic beverages have effectively fallen dramatically due to inflation. That's because such taxes are typically assessed not as a percentage of the purchase price, but as a flat dollar amount.

Those levies have been raised only once for beer and wine, and only twice for liquor in the past 55 years. Had the federal tax on beer merely kept pace with inflation, it would be more than triple what it is today. Liquor taxes would have increased sixfold.

Most Americans would be largely unaffected by increases in alcohol taxes. More than one-third don't drink at all, and most others drink only occasionally. Eighty percent of the alcohol consumed in America is downed by twenty percent of the drinkers. According to the Adams Beer Handbook, more than half of beer and liquor drinkers have incomes above $60,000 a year.

"Cutting social programs such as Medicaid, Medicare, and food stamps is an absolutely unconscionable way to cut the deficit so long as lawmakers are leaving billions in alcohol tax increases off the table," said Hacker.

"Especially when one considers that the $18 billion in current state and federal alcohol tax collections barely cover a tenth of the $185-billion price tag of underage drinking, alcohol abuse, and drunk-driving. Congress last found the courage to raise alcohol taxes in the Reconciliation Act of 1990, and it should follow that precedent today."

Last May, 59 prominent economists, including four Nobel laureates, called on Congress to raise alcohol taxes to help offset the massive economic and social costs of alcohol.

Henry Aaron, a senior fellow in economic studies at the Brookings Institution, said that lawmakers "would be well advised to increase a tax that would help close the federal deficit and discourage the continued epidemic of alcohol abuse."

In its 2005 budget options report for Congress, the Congressional Budget Office estimated that raising the tax on distilled spirits to $16 per proof gallon from the current rate of $13.50 and equalizing the rate of tax on the alcohol in beer and wine to that level would yield $27 billion in new revenue over the next five years.

Numerous researchers have concluded that higher taxes would lead to slightly less drinking, and could cut the incidence of alcohol problems and their costs. A nickel-a-drink tax increase might save as much as $5 billion per year.

Earmarking some of the revenues for alcohol treatment, prevention, and public education could further reduce the societal toll of alcohol problems, according to CSPI.

CSPI's survey was of a nationally representative sample of 512 American adults. The survey was conducted in mid-November via telephone by the Global Strategy Group polling firm. The margin of error is plus or minus 4.3 percent.

A small mention in an obscure regulatory filing with the Securities and Exchange Commission (SEC) reveals energy drink maker Monster Beverage is being investigated by a state attorney general.

Monster produces and markets a number of so-called energy drinks, including Monster Energy, Hansen's Energy and Blue Sky. The filing said the probe by the unnamed attorney general focused on advertising, marketing, promotion and ingredients.

A number of states in recent years have taken action against energy drinks that contain alcohol. Among the most recent are Washington State and Illinois. No state has announced it is investigating energy drinks, but of course such investigations are never announced in advance.

Increasing scrutiny

Energy drinks of all types have come under closer scrutiny at both the federal and state level. In an April letter to the Commissioner of the Food and Drug Administration (FDA), Sen. Dick Durbin (D-IL) called for an investigation into energy drinks like Monster Energy, Rockstar and Red Bull, which contain high levels of caffeine and ingredients some health authorities describe as potentially dangerous.

Durbin called for an investigation after learning the story of a 14 year-old girl from Maryland, Anais Fournier, who died last December of a cardiac arrhythmia due to caffeine toxicity after drinking two 24-ounce Monster energy drinks in a 24-hour period.

“Consuming large quantities of caffeine can have serious health consequences, including caffeine toxicity, stroke, anxiety, arrhythmia, and in some cases death," Durbin wrote in the letter. "Young people are especially susceptible to suffering adverse effects because energy drinks market to youth, their bodies are not accustomed to caffeine, and energy drinks contain high levels of caffeine and stimulating additives that may interact when used in combination.

Marketed to young people

Durbin also expressed concern that the beverages were being marketed to young consumers.

The medical profession generally advises young people to avoid energy drinks. In a 2011 report, the American Academy of Pediatrics said it found some of these products harmful.

“There is a lot of confusion about sports drinks and energy drinks, and adolescents are often unaware of the differences in these products,” said Dr. Marcie Beth Schneider, a member of the AAP Committee on Nutrition and co-author of the report. “Some kids are drinking energy drinks -- containing large amounts of caffeine -- when their goal is simply to rehydrate after exercise. This means they are ingesting large amounts of caffeine and other stimulants, which can be dangerous.”

In addition to stimulants like caffeine, energy drinks often have lots of calories. Calories from sweetened beverages increasingly are being blamed for contributing to obesity.