Factors influencing young people's use of alcohol mixed with energy drinks

Appetite 96 (2016) 408e415

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Factors influencing young people's use of alcohol mixed with energy drinks Simone Pettigrew a, *, Nicole Biagioni b, Sandra C. Jones c, Julia Stafford d, Tanya Chikritzhs e, Mike Daube d a

School of Psychology and Speech Pathology, Curtin University, Kent St, Bentley, Western Australia 6102, Australia Faculty of Health Sciences, Curtin University, Western Australia, Australia Australian Catholic University, Melbourne, VIC, Australia d McCusker Centre for Action on Alcohol and Youth, Curtin University, Western Australia, Australia e National Drug Research Institute, Curtin University, Western Australia, Australia b c

a r t i c l e i n f o

a b s t r a c t

Article history: Received 29 May 2015 Received in revised form 28 August 2015 Accepted 30 September 2015 Available online 9 October 2015

A growing evidence base demonstrates the negative health outcomes associated with the consumption of energy drinks (ED) and alcohol mixed with energy drinks (AMED), especially among young people. Work to date has focused on the physiological effects of ED and AMED use and the motivations associated with consumption, typically among college students. The present study adopted an exploratory, qualitative approach with a community sample of 18e21 year olds to identify relevant barriers, motivators, and facilitators to AMED use and to explicate the decision-making processes involved. The sensitisation method was used to collect data from a cohort of 60 young adult drinkers over a period of six months via individual interviews, focus groups, and introspections. The findings indicate that there may be a general understanding of the negative consequences of AMED use, and that these consequences can constitute barriers that serve to discourage frequent consumption among young people. This outcome suggests the potential application of positive deviance and social norms approaches in interventions designed to reduce AMED use among this population segment. The results are promising in the identification of a large number of concerns among young adults relating to AMED use. These concerns can constitute the focus of future communications with this target group. The results are likely to have relevance to other countries, such as the US and the UK, that share similar alcohol cultures and where energy drinks have achieved comparable market penetration rates. © 2015 Elsevier Ltd. All rights reserved.

Keywords: Alcohol Energy drinks AMED Young adults Qualitative Australia

1. Introduction The relatively recent advent of alcohol mixed with energy drinks (AMED) has resulted in limited knowledge of relevant decisionmaking criteria used by consumers (Burrows, Pursey, Neve, & Stanwell, 2013; Marzell, Turrisi, Mallett, Ray, & Scaglione, 2014). The potential harm caused by this product combination and the rapidly increasing size of the market indicate the need to better understand relevant choice processes (Pennay & Lubman, 2012). In particular, data are needed in relation to decision making processes of young adults who are the primary AMED user market and the target of extensive marketing for the energy drink (ED) product

* Corresponding author. E-mail address: [email protected] (S. Pettigrew). http://dx.doi.org/10.1016/j.appet.2015.09.037 0195-6663/© 2015 Elsevier Ltd. All rights reserved.

category (Babu, Church, & Lewander, 2008; Breda et al., 2014; Pomeranz, Munsell, & Harris, 2013; Reissig, Strain, & Griffiths, 2009; Zucconi et al., 2013). Much work on EDs has focused on their negative physiological effects, which include agitation, elevated blood pressure, sleep disturbance, increased susceptibility to addiction, dental caries, miscarriage, arrhythmia, and even death (Arria & O'Brien, 2011; Avci, Sarıkaya, & Büyükcam, 2013; Babu et al., 2008; Berger & Alford, 2009; Breda et al., 2014; Burrows et al., 2013; Clauson, Shields, McQueen, & Persad, 2008; Duchan, Patel, & Feucht, 2010; Finnegan, 2003; Greenwood et al., 2010; Marshall et al., 2003; Sepkowitz, 2013). Increasing concerns about the effects of EDs have resulted in calls for changes to policy and practice in this area, especially in relation to use by young people (Babu et al., 2008; Budney & Emond, 2014; Schneider et al., 2011; Seifert, Schaechter, Hershorin, & Lipshultz, 2011; Van Batenburg-Eddes,

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Lee, Weeda, Krabbendam, & Huizinga, 2014). However, progress has been slow, hampered by a lack of research providing definitive evidence of a causal relationship between the consumption of energy drinks and adverse physiological effects for young drinkers (Harris & Munsell, 2015). In the smaller field of AMED research, the focus has also been on young drinkers (Arria et al., 2010; Attila & Çakir, 2011; Berger, Fendrich, & Fuhrmann, 2013; Brache & Stockwell, 2011; Costa, Hayley, & Miller, 2014; Curry & Stasio, 2009; Droste et al., 2014; Hamilton, Boak, Ilie, & Mann, 2013; Jones, Barrie, & Berry, 2012; Kponee, Siegel, & Jernigan, 2014; Marzell et al., 2014; O’Brien, McCoy, Rhodes, Wagoner, & Wolfson, 2008; Penning, de Haan, & Verster, 2011; Varvil-Weld, Marzell, Turrisi, Mallett, & Cleveland, 2013; Velazquez, Poulos, Latimer, & Pasch, 2012; Woolsey, Waigandt, & Beck, 2010). Work to date suggests that AMED use in children predicts higher rates of alcohol consumption in the future (Miyake & Marmorstein, 2015). AMED use has also been associated with increased alcohol consumption, alcohol dependency, alcoholrelated harms, risky behaviour, and suicidal ideation among some users (Berger & Alford, 2009; Bonar et al., 2015; Brache & Stockwell, 2011; Marczinski, Fillmore, Henges, Ramsey, & Young, 2013; Martz, Patrick, & Schulenberg, 2015; McKetin, Coen, & Kaye, 2015; Patrick & Maggs, 2014; Peacock & Bruno, 2015; Thombs et al., 2010; Woolsey et al., 2015). US studies suggest that prevalence rates are high, with around half of underage drinkers aged 13e20 years reporting consuming AMED in the last 30 days (Kponee et al., 2014). Research examining user motivations has found staying awake, enhanced intoxication, sociability, and taste to be primary factors (Costa et al., 2014; Droste et al., 2014; Jones et al., 2012; Marczinski, 2011). At least some users demonstrate awareness of the dangers associated with AMED (Jones et al., 2012), although there is little understanding of how young people negotiate the perceived benefits and risks of combining the two substances. The present study contributes to the limited knowledge on young adults’ AMED-related decision-making. A qualitative approach was used to explore attitudes to AMED, the various contexts in which AMED is used, and the factors that influence consumption decisions. This approach reflects the need to identify and describe the complex processes involved with these kinds of consumption choices (Bunting, Baggett, & Grigor, 2013). It also acknowledges the limited prior research in this field and hence the need to utilise exploratory methods to lay the groundwork for future work (Jones et al., 2012). The study was conducted in Australia, where one in two young adults report AMED use (Foundation for Alcohol Research and Education, 2013) and the ED market quadrupled over the decade to 2010 (Canadean, 2011). 2. Method Data relating to young adults’ ED use were captured as part of a larger study investigating alcohol-related beliefs and behaviours among regular alcohol drinkers aged 18e21 years. Regular drinking was defined as consuming alcohol at least two days per month. The study employed the sensitisation approach (Pettigrew & Pescud, 2013), which involves using multiple qualitative methods to collect data over a period of six months from a cohort of individuals exhibiting characteristics of interest (in this case, young adult drinkers). The aim of the sensitisation approach is to generate deep insights over and above what may be shared in a single interview or survey. Sixty young people were recruited to participate in individual interviews, focus groups, and fortnightly emailed introspections. During these data collection episodes, participants were invited to discuss their beliefs and behaviours in relation to ED and AMED use.

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Ethics approval for the study was obtained from the Curtin University Human Research Ethics Committee and all participants provided informed consent. 2.1. Participants A social research agency recruited participants by disseminating invitations to their database members who met the eligibility criteria of age (18e21 years), alcohol consumption status (minimum of two drinking episodes per month), and place of residence (Perth, Western Australia). The invitation offered the opportunity to “participate in a study about alcohol consumption”. In addition to the emailed invitations, recruitment advertisements were placed on various websites and social media platforms. Of the 380 individuals who responded to the invitation/advertisements, 106 were excluded due to ineligibility or full gender/age quotas, and a further 197 indicated that they were unable to commit to the study for the full six months. Of the remaining 77 potential participants, 17 withdrew upon initial contact with the researchers, resulting in a final sample of 60 drinkers. Average daily alcohol consumption for each participant was calculated using the method adopted in national alcohol intake surveys (Australian Institute of Health and Welfare, 2011, 2014). This involved participants reporting the frequency with which they consumed alcohol in the previous 12 months and the number of standard drinks consumed on a typical drinking occasion. One-third of the sample members reported typical alcohol intake levels classified as low risk for long-term alcohol-related harm (i.e. an average of no more than two drinks per day (National Health and Medical Research Council, 2009). The other two-thirds were classified as being at high risk because their reported average alcohol consumption exceeded this level. The study participants were classified into three segments according to their ED usage (i.e., ED in any form, with or without alcohol): non-users (n ¼ 17), infrequent users (n ¼ 22), and frequent users who consumed at least weekly (n ¼ 21). Those in the non-user category included participants who had never consumed EDs or had tried them in the past but subsequently decided to abstain. Those in the infrequent user category considered themselves to be current users but reported consuming EDs less frequently than weekly. The groups were of similar size, with around one-third of the sample falling into each segment (see Table 1). 2.2. Procedure The sensitisation method involved participants providing a total of 15 data inputs over six months: two individual interviews, one focus group, and 12 introspections. Participants were remunerated up to $AUD600 across the six months if all data collection tasks were completed (an average of $AUD40 per data collection episode). Most participants completed most data collection tasks over the study period, with 49 participants completing at least 12 tasks. The interviews were conducted at the start and middle of the study, and the focus groups were conducted at the end. The topics of EDs and AMED were raised in all interviews and focus groups, which were conducted in a semi-structured format. Participants' fortnightly introspections constituted emailed notes about their thoughts and feelings pertaining to any alcohol-related topic of their choice. Reminders were distributed via email each fortnight to enhance compliance and encourage ongoing participation in the study. The aim of the introspection component was to allow participants to consider topics in their own time, thereby giving them the opportunity to reflect on relevant issues and provide more considered responses (Gould, 1995). Participants received a list of

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Table 1 Sample profile by ED status (n ¼ 60). Participant characteristics Gender Male Female Age 18 19 20 21 Occupation Student Worker Unemployed Parent Socioeconomic statusa Low Medium High Average alcohol intake Low High a

Non-users of EDs n ¼ 17

Infrequent users of EDs n ¼ 22

Frequent users of EDs n ¼ 21

Total

7 10

12 10

11 10

30 30

1 5 5 6

3 9 3 7

8 3 4 6

12 17 12 19

8 6 2 1

12 8 1 1

15 3 2 1

35 17 5 3

5 2 10

9 4 9

7 6 8

21 12 27

9 8

7 15

4 17

20 40

SES of suburb of residence assessed as per the Australian Bureau of Statistics' (2011) socio-economic indexes for areas (SEIFA) postcode rating.

optional topics that they could discuss in their introspections, one of which was energy drinks. The wording of this optional topic was “Please give us your thoughts on energy drinks, with and without alcohol”. After the study was completed, all participants were provided with information relating to the National Health and Medical Research Council's (2009) alcohol consumption guidelines and were advised of the availability of alcohol-related services in the local community. 2.3. Analysis The interviews and focus groups were audio recorded (with signed, informed consent) and subsequently transcribed. The resulting transcripts and introspections were analysed using NVivo10. The data were coded to a range of attitudinal, behavioural, and demographic variables. NVivo's text and matrix search functions were then used to (i) identify barriers, motivators, and facilitators to AMED use and (ii) explicate the factors that appeared to influence the consumption decision-making processes of the sample members. In the context of health promotion research, barriers constitute factors that prevent or discourage a particular behaviour, motivators are factors that encourage the behaviour, and facilitators are elements of the external environment that are conducive to the behaviour (Dev, Speirs, McBride, Donovan, & Chapman-Novakofski, 2014). The general approach to analysis was a thematic interpretation using the constant comparative method (Glaser & Strauss, 1967). This involved noting the content of participants' discussions, the frequency and intensity with which they expressed certain views, and the extent of similarity and variation between different participants' reported attitudes and behaviours. The first and second authors performed the coding task, with discussions undertaken to reconcile any differences in interpretation. The coded data were then discussed among the author team to facilitate identification of relevant barriers, motivators, and facilitators. In addition, a decision tree reflecting various dimensions of participants' decision-making processes was developed to provide insight into key attitudinal and behavioural pathways that appeared to influence AMED consumption among the sample members. Borrowed from the data mining literature where graphical representations of consumers’ decision heuristics are represented in a hierarchical structure (Arentze & Timmermans, 2005), decision trees can also be useful in

representing decision processes identified in qualitative research (Auld et al., 2007). 3. Results As shown in Table 1, ED use was most common among the younger participants, students, and heavier alcohol consumers. Only two members of the sample reported consuming EDs without ever combining them with alcohol, one of whom was a frequent ED user and one an infrequent ED user (both consumed alcohol at high-risk levels). The remainder of the ED users reported currently consuming EDs with alcohol at least some of the time. In their accounts of why they did or did not consume AMED, participants nominated a wide range of barriers, motivators, and facilitators. The barriers category contained the largest number of factors (9) relative to the motivators (6) and facilitators (3) categories. This high level of awareness of negative factors is consistent with only a minority of the sample regularly consuming AMED and the majority choosing to either abstain or consume infrequently. Overall, the barriers, motivators, and facilitators fell into the subcategories of health concerns, functional outcomes, social outcomes, and financial considerations (see Table 2). Participant quote descriptors below use the following key: participant number (P1eP60), gender (M/F), age (18e21), ED consumption status (frequent ED/infrequent ED/no ED), alcohol consumption risk status (low alc/high alc), and data source (interview/introspection/FG (focus group)). 4. Barriers Health concerns dominated the identified barriers to AMED use. The most commonly cited barrier was the anticipated negative physiological effects, which included anxiety, hyperactivity, aggression, sleep disruption, exacerbated hangover, heart palpitations, cardiac arrest, and death. Some participants reported having personally experienced side-effects, while others had heard about them from peers and other sources. Overall, there was a high level of awareness that AMED use has associated risks: I can't have Red Bull, it makes my heart way too fast. And one of my friends, her friend's boyfriend had a heart attack because he had

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Table 2 Factors influencing use of AMED among 18e21 year old alcohol drinkers.a Barriers

Motivators

Facilitators

Fear of moderate to severe health outcomes (HC) Desire to avoid caffeine addiction (HC)

Peer consumption (bonding) (SO) Peer pressure (SO)

Low caffeine tolerance levels (HC) Taste (FO) Cost (FC) Exacerbated hangover (HC) Sugar content (HC) Chemicals/additives (HC) More side-effects than illicit drugs (HC)

Extended partying (FO) Intensified inebriation (FO) Taste (FO) Rebellion (SO)

Price discounting (FC) Purchasing ingredients separately and self-mixing (FC) Sugar free alternatives (FO)

a

HC ¼ health concern, FO ¼ functional outcome, SO ¼ social outcome, FC ¼ financial consideration.

too many Red Bull vodkas. So that's me off energy drinks (P1, F, 21, no ED, low alc, interview).

by eating cake than drinking energy drinks;) (P22, F, 19, infrequent ED, low alc, introspection).

I really hate Red Bull and those crazy drinks ‘cause they make me feel really ill (P29, M, 19, no ED, high alc, interview).

Energy drinks often have harmful additives such as sugar and food colour, which are intrinsically bad (P26, M, 19, infrequent ED, high alc, introspection).

Generally alcohol is a downer drug and energy drinks are uppers so they can have contradictory responses in your body e I have certainly felt the feeling at 4am of my body being exhausted but my mind not letting me sleep as the caffeine is keeping it alert (P43, F, 19, frequent ED, high alc, introspection). Female participants were more likely than males to report being concerned about potential negative health effects of AMED use. Non-users had the highest levels of concern about health risks, but infrequent users were most likely to extensively discuss negative outcomes due to their own experiences with AMED. Even some of the frequent users acknowledged that AMED use is problematic for health reasons. I suffer from drinking too many energy drinks. I get chest pain, irritated and I will shake for no reason. This occurs regardless of whether I've mixed the energy drink with the alcohol or not. I hate waking up and feeling so run down. It's worse than a hangover because I was on such an energy high the night before and the crash from too many energy drinks is horrible…Personally, I'll drink energy drinks with or without alcohol. For me, the energy high is the same and for a few hours at least, I'm like an energizer bunny and I dance more and have a better time. Afterwards however, I suffer for it big time (P7, F, 18, frequent ED, low alc, introspection). A general aversion to caffeine was evident among some participants, largely based on its recognised dependency properties and a reluctance to commence a caffeine ‘habit’. I just try to avoid kind of coffee and stuff because I know people who can't wake up without like two coffees in the morning…I just don't want another habit really, yeah (P30, M, 20, infrequent ED, high alc, interview). Some acknowledged that they had low caffeine tolerance levels, and hence combining EDs with alcohol could be especially problematic for them. There was also a general sense that they understood their use of alcohol was already putting them at risk of harm and adding EDs could be ‘a step too far’. Other health concerns related to the sugar content of EDs and the presence of food additives and other chemicals that were perceived to be unhealthy. Alternative mixers were therefore often considered to be more acceptable. I know they're worse for you than other mixers because of their relatively high sugar content. I'd rather consume my extra calories

In addition to health concerns, unappealing taste was a substantial barrier to many participants in the non-user and infrequent-user segments. Cost was a further limiting factor, especially in terms of AMED use in licenced premises. They're expensive, they taste weird, they don't make you feel that good, so I'm not really into them (P3, F, 20, no ED, low alc, interview). 4.1. Motivators Social and functional outcomes were the most commonly reported motivators for AMED consumption. Of primary influence among the social outcomes was the need to comply with implicit and explicit expectations of peers. There was considerable discussion of having AMED beverages thrust upon them and being coerced to consume these drinks as part of celebration rituals. There was a sense of ‘one in, all in’, resulting in a reluctance to be the odd one out. I occasionally drink Jager bombs (type of AMED), but, that's only if I'm very drunk and I kinda get pressured into it (P45, F, 21, infrequent ED, high alc, interview). There have been times where I was already drunk and drinking what my friends were drinking or buying me. I didn't choose to drink them to get more drunk or stay awake, it was purely just what everyone else was drinking or what someone ordered for me (P11, F, 19, infrequent ED, high alc, introspection). AMED also provided a mechanism by which participants could demonstrate their independence and ability to make their own decisions. For some, this involved intentionally flouting the recommendations of authority figures. I drink vodka Red Bull and take Jager bombs. Like, I am a teenager, so just like everyone's like, ‘Don't do that’, but I'm like, ‘Nah, I'll do it’ (P54, F, 19, frequent ED, high alc, FG). In terms of functional outcomes, AMED use was widely perceived to enable party-goers to stay up longer and hence extend the enjoyment of social events. It was also described as facilitating faster and more acute levels of inebriation, attributes that were considered beneficial in enhancing the drinking occasion. In contrast to those who perceived the taste of EDs to be unpleasant,

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some participants found the flavour highly palatable. Just helps you get more excited for the night ‘cause we are usually pretty tired from the week and everything. And then we can get energy and be drunk and we can do that at the same time (P31, M, 18, frequent ED, high alc, interview). Energy drinks really taste good because of the high sugar content (P37, M, 21, frequent ED, high alc, introspection). 4.2. Facilitators The most important facilitator related to financial considerations. The high cost of AMED products in licenced premises resulted in those wishing to consume these products seeking methods of obtaining them at reduced prices. This was achieved by attending events in licenced premises that feature ‘happy hours’ (heavily discounted drink prices for a limited time period) and/or purchasing alcohol and EDs separately at off-licence venues and mixing the two products themselves. Red Bull and vodka is a popular choice for me, and I usually drink it on a Wednesday night at the pub when they're $6 each (P7, F, 18, frequent ED, low alc, introspection). For a small number of participants, the ability to source sugarfree varieties made AMED products more attractive. These individuals were a small minority, and most participants did not appear aware of this alternative. I sometimes prefer the zero sugar Red Bull because the normal ones have really high calories (M, 21, frequent ED, high alc, introspection).

4.3. Decision-making process for AMED Based on the study findings, a proposed decision tree for AMED use among young adult drinkers is depicted in Fig. 1. Reflecting the dominance of health concerns, the first stage in the tree is the level of concern about the potential negative consequences associated with consuming EDs. Those participants with the greatest concern chose to abstain from AMED. Those with few concerns were the heaviest AMED users, while those with medium-level concerns tended to belong to the infrequent-use segment. Among those in

the medium-concern category, the likelihood of AMED use appeared to be higher among those whose peer groups were heavy users and who regularly attended night clubs. The relationship between clubbing and AMED use was reported to be due to the late hours involved and the resulting need for stimulants to stay awake and alert. We tend to know it's bad for you, but who cares?...It really pumps you up. For me personally, energy drinks are a must because beers or alcohol by themselves are not good enough to pump you up, and in fact after a couple of hours of many beers, you tend to get sleepy. Therefore, if you want a good night, energy drinks are essential, as well as alcohol (P37, M, 21, frequent ED, high alc, introspection). If I've had a long day, and then if we've got a party that night that may go a little bit later, I might have one or two to perk me up (P19, F, 21, infrequent ED, low alc, interview). For some of the participants in the medium-concern category who reported taking illicit drugs, AMED use appeared to be reduced because the drugs were perceived to have more advantages and fewer side-effects than EDs. This is where other drugs come into play, such as dexies (dexamphetamine) and ritiez (ritalin). These stimulants give me way more energy than caffeine ever could, and combined with the induced dopamine release, these are a much better option than a vodka Red Bull (P44, M, 19, frequent ED, high alc, introspection). Dexies keep you awake and alert, heighten sociability and talkativeness, and give you physical energy. They are relatively inexpensive, easy to acquire and consume, and don't make you feel sick or give you a hangover (P22, F, 19, infrequent ED, low alc, introspection). Those in the low-concern group were found to also exhibit the motivating factors of peer consumption and club attendance, with pre-drinking activities representing an additional factor. There was a particular tendency for these participants to commence drinking at private homes before moving on to licenced venues. Pre-drinking AMED was undertaken to increase the total amount of alcohol consumed in the evening and to reduce the costs associated with heavy drinking in nightclubs. At most house parties or pre drinks, my first drink will be an energy drink with vodka. I start with an energy drink because it wakes and

Fig. 1. Proposed AMED decision tree for young adult drinkers. Arrows between cells represent identified relationships between attitudinal and behavioural outcomes within the sample population. Arrows within cells represent increased or decreased likelihood of AMED consumption.

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livens me up immediately so I can get into the party fast and don't need to wait for the alcohol to kick in. It makes me feel drunk sooner and more energetic, which is perfect for house parties with friends (P48, M, 18, frequent ED, high alc, introspection). If people do have them, it's normally at pre's to get them ready for the night. I think it might be a little bit cheaper to do it that way also (P11, F, 19, infrequent ED, high alc, introspection). 5. Discussion While the qualitative approach and small sample limit the generalizability of these findings, the proportion of AMED users in this sample of young adults (approximately two-thirds) is consistent with that reported elsewhere (Berger et al., 2013). In addition, the identified motivations for consumption are similar to those found in previous Australian research (Droste et al., 2014; Jones et al., 2012; Peacock, Bruno, & Martin, 2013), and the findings support previous work indicating the extent to which EDs have permeated the endemic alcohol culture in Australia (Jones et al., 2012; Pennay et al., 2015). The sensitisation approach adopted in the present study was found to be efficacious in producing a large amount of relevant data, and thus could be appropriate for generating insights into the AMED phenomenon in other locations. A particular contribution of the present study is the identification of numerous barriers that factor into young adults’ decisions to avoid or minimise AMED consumption. The extent to which the study participants were already aware of negative outcomes indicates that education alone is unlikely to be adequate to encourage reduced consumption among current drinkers and discourage use among future drinkers. This has implications for interventions designed to address AMED use given regular calls for greater youth education as a harm minimisation strategy (Gunja & Brown, 2012; Howland & Rohsenow, 2013; Pennay & Lubman, 2012; Pennington, Johnson, Delaney, & Blankenship, 2010; Weldy, 2010). While education is a likely to be a necessary component of harmminimisation efforts, the findings suggest a need to build on existing perceptions and experiences to ensure messages are relevant and meaningful for the target audience. The finding that there was a general understanding of the negative consequences of AMED use but different behavioural responses among the sample members suggests that the principles of positive deviance may be useful for developing effective interventions. Positive deviance is the process by which some individuals within a toxic environment do well while others do not (Marsh, Schroeder, Dearden, Sternin, & Sternin, 2004). The successful strategies used by these individuals can be communicated and modelled to others, providing behavioural guidance that can have perceived legitimacy due to the demonstrated effectiveness among peers (Singhal, 2010). Communicating to young people that others share the same concerns and suggesting alternative strategies that are used by their peers may provide the motivation and ability to reduce or avoid AMED use. This approach is consistent with the social norms framework that emphasises the potential value of aligning perceived and actual norms within population segments (Perkins, 2002). The decision tree analysis highlights the potential relevance of specific social contexts in encouraging and facilitating AMED consumption. This finding is consistent with previous work that has highlighted the influence of social contexts on AMED consumption, particularly in relation to pre-drinking activities (Bulut, Beyhun, Topbas¸, & Çan, 2014; Pennay et al., 2015). In the present study, attendance at pre-drinking sessions and nightclubs were found to be associated with AMED consumption among both

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infrequent and frequent users. Positive deviance and social norms strategies could therefore focus on the ways non-AMED users construct enjoyable experiences in these contexts. Future research could investigate these alternative behaviours and effective means of communicating them to the target group. In particular, such strategies would need to accommodate the effects of inebriation on decision-making. Once intoxicated, knowledge of adverse outcomes may be insufficient to support intentions in regard to consumption minimisation or avoidance. As shown in the decision tree analysis, even some participants who had concerns about the health effects of EDs reported consuming more AMED once they were immersed in drinking environments. The results of the present study are aligned with previous research indicating that heavy AMED use is associated with heavy alcohol consumption (Arria et al., 2010; Velazquez et al., 2012). As shown in Table 1, the heaviest users of ED in this study were also the heaviest consumers of alcohol. This suggests that ongoing efforts to reduce binge drinking among young people may have beneficial effects on ED and AMED consumption, thereby providing further justification for such programs. Conversely, reducing AMED use may have the favourable outcome of reducing alcohol consumption among heavy drinkers. The findings also support other work that has emphasised the need for tighter regulations on the supply and promotion of EDs (Brache & Stockwell, 2011; Breda et al., 2014; Jones et al., 2012; Pennay & Lubman, 2012; Pomeranz et al., 2013; Reissig et al., 2009). The ready availability of inexpensive AMED products through venue ‘happy hours’ and off-licence stores facilitated participants' consumption, indicating that regulations addressing these forms of supply may assist in reducing demand. In addition, limiting ED promotion has the potential to assist positive deviance strategies that seek to de-normalise ED and AMED consumption. This study has limitations that stem from the methodological approach adopted. The relatively small sample means that the findings are tentative and need to be assessed quantitatively among larger and more representative samples. A quantitative approach would also assist in overcoming the constraints of the introspection data collection method whereby participants were not always clear about whether they were referring specifically to EDs or AMED. In addition, the relationships proposed in the decision tree need to be tested to measure the accuracy and size of the postulated effects. To conclude, a typology of barriers, motivators, and facilitators to AMED use among young people has been generated that can guide future intervention efforts. The decision tree analysis highlights the importance of considering specific social contexts when developing interventions that address these factors. Overall, the results suggest that positive deviance and social norms approaches have the potential to improve outcomes for young people by (i) assuring them that their peers share their views and (ii) providing tangible and realistic alternatives to AMED use. The study findings are likely to have relevance to other countries with similar alcohol cultures and energy drink consumption rates among young adults. Funding source This study was funded by a research grant from the Drug and Alcohol Office (Healthway Grant # 24033). Declaration of interest None to declare.

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