Earlier this year, a half-dozen students from City Hill Middle School in Naugatuck, Connecticut traveled with their science teacher Katrina Spina to the state capital to testify in support of a bill that would ban sales of energy drinks to children under the age of 16. Having devoted three months to a chemistry unit studying the ingredients in and potential health impacts of common energy drinks—with brand names like Red Bull, Monster Energy, and Rockstar—the students came to a sobering conclusion: “Energy drinks can be fatal to everyone, but especially to adolescents,” 7th-grader Luke Deitelbaum told state legislators. “Even though this is true, most energy drink companies continue to market these drinks specifically toward teens.”
A 2018 report found that more than 40% of American teens in a survey had consumed an energy drink within the past three months. Another survey found that 28% of adolescents in the European Union had consumed these sorts of beverages in the past three days.
This popularity is in marked contrast to the recommendations of groups like the American Academy of Pediatrics and the American College of Sports Medicine, who say youth should forgo these products entirely. These recommendations are based on concerns about health problems that, although rare, can occur after consumption, including seizures, delirium, rapid heart rate, stroke, and even sudden death. A US government report found that from 2007 to 2011, the number of emergency department visits involving energy drinks more than doubled, to nearly 21,000.
Of these, approximately 1,500 were children aged 12 to 17, although the number of visits from this age group increased only slightly over the four years.
For their part, energy drink manufacturers argue that they are being unfairly targeted. At the Connecticut hearing, the head of public affairs for Red Bull North America, Joseph Luppino, maintained that there is no scientific justification to regulate energy drinks differently than other caffeine-containing beverages such as soda, coffee, and tea—particularly when some coffeehouses serve coffee with a caffeine content exceeding that of a can of Red Bull. “Age-gating is an incredibly powerful tool,” Luppino said, and should be reserved for “inherently dangerous products” like nicotine.
The showdown in Connecticut, which pitted the City Hill students against a growing $55 billion a year global industry, was the latest in an ongoing debate about the safety and regulation of energy drinks. In recent years, countries such as the United Kingdom and Norway have considered banning sales to young people, while Lithuania and Latvia have active bans in place. In the US, along with Connecticut, state legislators in Maryland, Illinois, and Indiana have introduced bills, though none have been signed into law. A South Carolina bill to ban sales to kids under 18—and to fine those caught selling them to minors—advanced through the legislature in April, and is now pending before the state’s full medical affairs committee. It is supported by the parents of a 16-year-old who died from a caffeine-induced cardiac event after consuming a coffee, a soda, and an energy drink within a period of two hours.
As the regulatory status of energy drinks continues to be debated, a growing number of consumers and public health advocates are asking why and how a product loaded with caffeine and other stimulants became so popular among young people. The reasons are a mix of lax regulation, the use of caffeine as a sports performance enhancer among adults, and a bit of scientific uncertainty.
According to sports cardiologist John Higgins, a professor at McGovern Medical School at UTHealth in Houston, there is also another factor: “very, very intelligent advertising.”
Historically, government agencies such as the US Food and Drug Administration have struggled to regulate beverages with added caffeine. Though it offers some guidance, the FDA allows manufacturers of liquid products to decide on their own whether to market their products as dietary supplements, or as conventional foods and beverages, which carry differing regulatory requirements. All three major energy drink makers now have most of their products regulated as foods, rather than dietary supplements—though that wasn’t always the case.
Researchers from the Johns Hopkins School of Medicine, in a review published in the journal Drug and Alcohol Dependence, note that lack of consistency is partly due to our long love affair with drinks in which caffeine is naturally occurring, including coffee and tea. In 1980, citing health concerns, the FDA proposed to eliminate caffeine from soft drinks, which are regulated as foods. The manufacturers, however, claimed the caffeine was a flavor enhancer. The FDA approved caffeine, but limited the maximum content of cola-type soft drinks to .02%, or roughly 71 milligrams per 12-ounce serving.
“If caffeine had not been accepted as a flavor enhancer, but had been regarded as a psychoactive ingredient,” write the Johns Hopkins researchers, “soft drinks might have been regulated by the FDA as drugs”—which are subject to additional regulations.
When energy drinks first appeared on the American market in the late 1990s and early 2000s, some manufacturers claimed the products were neither drugs nor conventional foods, but dietary supplements. Drugs with caffeine require warning labels, but dietary supplements don’t. “It is a striking inconsistency that, in the US an [over-the-counter] stimulant medication containing 100 mg of caffeine per tablet (e.g. NoDoz) must include [a series of] warnings,” write the Johns Hopkins researchers, “whereas a 500 mg energy drink can be marketed with no such warnings and no information on caffeine dose amount in the product.”
As early as 2009, sports and medical organizations began issuing position statements discouraging energy drink consumption by young people. In 2011, the American Academy of Pediatrics concluded that energy drinks “are not appropriate for children and adolescents, and should never be consumed.” Further, the group warned that adolescents might mistakenly use energy drinks, rather than sports drinks like Gatorade, for rehydration during physical activity. “Advertisements that target young people are contributing to the confusion,” wrote the authors.
Two years later, in 2013, questions about safety and marketing came to a head in the halls of Congress. Three Democratic senators launched an investigation into the marketing practices of energy drink companies. They found that adolescents between the ages of 13 and 17 are frequent targets of energy drink marketing, and stated in a written report that “this population is also at risk for the detrimental impacts of energy drink consumption.” The report also noted a range of claims not evaluated or substantiated by the FDA. For example, the makers of AMP Energy marketed the drinks as helping to “energize and hydrate the body,” while advertisements for Red Bull promised “increased concentration and reaction speed.”
(As it happens, a few months before the senate hearing, Monster Beverage Corporation and Rockstar Inc. announced their intention to follow in the footsteps of Red Bull by declaring their products to be foods, rather than dietary supplements.)
Among those providing testimony at a committee hearing was Jennifer L. Harris, a researcher at the Rudd Center for Food Policy and Obesity, currently housed at the University of Connecticut. She and her team had conducted an earlier study of how sugary beverages are marketed to children. “What we learned about energy drinks stunned us,” she said at the hearing.
Energy drink companies had been pioneers in using social media to market their products, said Harris. At the time of her study, Red Bull and Monster Energy were the fifth and twelfth most popular brands on Facebook—a platform that was, at the time, particularly popular among college students and adolescents. Further, said Harris, “energy drink brands often promote teen athletes and musicians and sponsor local events, where they provide free samples, including to minors.” The marketing is effective, she noted. Sales of most other beverage categories were declining, but energy drink sales had increased by 19% the previous year, reaching $8 billion in 2012.
The energy beverage industry vigorously defended its products and marketing practices. In his congressional statement, Rodney Sacks, CEO of Monster Beverage Corporation, noted that a 16-ounce can of Monster Energy contains 160 mg of caffeine. In contrast, the equivalent amount of Starbucks coffee contains 330 mg—more than twice as much. Further, Monster cans include a label recommending against consumption by children. (According to guidelines put forth by the American Beverage Association, a trade group, energy drinks should not be marketed to children under 12, and other leading brands such as Red Bull and Rockstar carry similar labels recommending against consumption by children.)
Further, Sacks and representatives from Rockstar, Inc. and Red Bull North America denied that their companies advertise to young teenagers. Doing this, said Sacks, “would undermine the credibility of the brand image in the eyes of young adults,”—nominally their target consumer demographic.
Not everyone buys this. A 2017 study published in the journal Public Health Nutrition, for example, tested whether young consumers perceived energy drink advertising as being targeted at people their age and younger. Researchers at the University of Waterloo randomly assigned over 2,000 Canadians aged 12 to 24 to view one of four online ads for Red Bull. Among the youngest subjects—those aged 12 to 14—nearly 72%of participants who viewed an advertisement featuring the company’s sponsorship of the X Games, an extreme sports event, perceived the ad to be targeted to people their age and younger.
The University of Waterloo researchers compare energy drink marketing practices with those of 20th-century cigarette companies. “While tobacco advertising was ostensibly targeted only at adults,” they write, “it nevertheless achieved very high levels of reach and appeal among young people.”
Further, and perhaps not surprisingly, across all age groups, 71% of those who were shown a Red Bull ad with a sports theme—the X games, for example, or an image of an airborne snowboarder with accompanying text reading “RED BULL GIVES YOU WIIINGS”—thought the ad they viewed promoted the use of energy drinks during sports.
This is a problem, says Matt Fedoruk, chief science officer at the US Anti-Doping Agency (USADA). Though his organization is perhaps best known for its role in testing Olympic athletes for banned substances, it also promotes a positive youth sports culture. Fedoruk says they field questions about energy drinks from athletes of all ages.
“Caffeine is the most studied ergogenic aid on the planet,” says Fedoruk, and its use is widespread among elite athletes. Research has even produced recommended guidelines for ingestion prior to exercise. But these guidelines were developed for adults. Young people who try to follow them could quickly surpass the American Academy of Pediatrics’ guidelines for adolescents: no more than 100 mg of caffeine per day, or roughly the amount in a typical cup of coffee. Further, because energy drinks are manufactured in adult serving sizes, says Fedoruk, it’s easy for a child to get too much. “Depending on the product you choose, you could definitely be dosing your young child or youth athlete in doses that far exceed what may be safe for their body weight and size.”
When it comes to youth athletes, “our experts recommend both water and sports drinks as the best options for hydration,” writes Danielle Eurich, a USADA spokesperson. Athletes exercising less than an hour probably don’t even need sports drinks, she adds. “Water would be best.”
Last year, John Higgins, the sports cardiologist, ran a small study in which healthy medical students downed a 24-ounce can of Monster Energy. Ninety minutes later, the students’ arteries were measured to test their ability to bounce back—or dilate—after being compressed by a blood pressure cuff. Dilation helps control blood flow, increasing circulation when necessary, including during exercise. In this study, the medical students’ blood flow was “significantly and adversely affected,” says Higgins.
Higgins suspects that the combination of ingredients—the caffeine and other stimulants such as guarana, taurine, L-carnitine, along with added vitamins and minerals—interferes with the endothelium, a thin layer of cells that control dilation. But he can’t say for certain because there hasn’t been enough research. Higgins’ own study was preliminary and lacked a control group. Further, a recent review by a group of Harvard researchers noted considerable limitations to the existing energy drink literature. Most studies, the authors found, used small sample sizes or employed a cross-sectional design, which isn’t able to determine causation. Large longitudinal studies, meanwhile, require time and money.
Higgins says the main reason there is no evidence of safety is that energy drinks are not classified by most countries as drugs. “They are classified as supplements, additives, or whatever.” Until more data are available, Higgins’ opinion is that energy drinks should be avoided before, during, and after exercise. Anyone under 18 should avoid them entirely, he says. This recommendation has been endorsed by the American College of Sports Medicine.
Yet at the Connecticut hearing, Red Bull’s Joseph Luppino insisted that there is ample evidence of safety. He referenced the European Food Safety Authority, which conducts food-chain risk assessments for the European Union: “They have unequivocally concluded there are no synergistic effects between the various ingredients that are contained in energy drinks.”
When asked for a comment, the European agency pointed to its 2015 report, and a spokesperson explained the findings: In general, the combination of substances typically found in energy drinks “would not affect the safety of single doses of caffeine up to 200 mg.” Individuals who might drink a 16-oz can of Rockstar, or a 24-oz can of Monster containing 240 mg of caffeine plus other stimulants were not considered by the analysis. The EU agency spokesperson also issued a caveat: There wasn’t enough data to determine whether other common energy drink ingredients like guarana and taurine influence the acute effects of caffeine on blood pressure.
Monster and Rockstar did not respond to repeated requests for comment. When asked about the discrepancy between Luppino’s characterization of the European report and the agency’s own characterization of its findings, Erin Mand, a spokesperson for Red Bull, pointed to particular passages in the report that suggest the safety of particular ingredient combinations up to 200 mg of caffeine. She additionally noted that “its single-serving products fall under 200 mg of caffeine.”
The American Beverage Association also did not respond to specific interview questions, but did provide this statement: “Energy drinks have been enjoyed by millions of people around the world for more than 30 years, and are recognized by government health agencies worldwide as safe for consumption. The amount of caffeine in energy drinks is typically half the amount found in a coffeehouse coffee and is no different from the caffeine found in other foods and beverages. Further, America’s mainstream energy drink companies have taken voluntary steps to ensure their products are not marketed to children.”
In the spring of 2017, Gary Watts, the coroner for South Carolina’s Richland County, released the autopsy results for Davis Cripe, the teenager whose death spurred the South Carolina bill to ban sales of energy drinks to minors. The cause of death: a caffeine-induced cardiac event causing a probable arrhythmia. “Typically you don’t see the results of an arrhythmia in an actual autopsy because there’s no real damage to the heart,” Watts said.
After Cripe collapsed at school, a staff member who had previously worked as a nurse in a cardiac unit diagnosed a cardiac arrhythmia.
“Who’s to say that this hasn’t happened before?” says Watts, whose office has performed autopsies on other young adults who died of sudden death. “It probably has—it’s just that we’ve not been able to document [the cause] with someone on the scene at the time who says, ‘Okay, this is an arrhythmia.’” Watts believes there are too many uncertainties about energy drinks to say that they are safe for adolescents. “I’m not trying to get rid of energy drinks,” he said. “I know a lot of people use them. But I do think that the age is a concern that everybody needs to be really serious about.”
As for the Connecticut bill, it has not moved out of committee, but in mid-May, the City Hill Middle School students and their teacher returned to the state capital to lobby lawmakers. They shared informational brochures created by the students, as well as informal results from a survey of students and parents, indicating widespread support for their bill among the latter. In the meantime, the students say, their siblings and peers continue to consume energy drinks—on soccer fields, in dugouts, in front of video game consoles.
“It’s so interesting,” City Hill student Emily Fine said of energy drink makers and their products, “how they still put them on the market.”