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PUBLIC HEALTH
REVIEW ARTICLE
published: 14 October 2014
doi: 10.3389/fpubh.2014.00134
Energy drink consumption in Europe: a review of the risks,
adverse health effects, and policy options to respond
João Joaquim Breda1*, Stephen Hugh Whiting 1, Ricardo Encarnação1, Stina Norberg1, Rebecca Jones1,
Marge Reinap2and Jo Jewell1
1Nutrition, Physical Activity and Obesity Programme, Division of Noncommunicable Diseases and Life-Course,World Health Organization Regional Office for
Europe, Copenhagen, Denmark
2WHO Country Office for Estonia,Tallinn, Estonia
Edited by:
Sanjay P. Zodpey, Public Health
Foundation of India, India
Reviewed by:
Donna Jeanne Petersen, University of
South Florida, USA
Milka Dancevic Gojkovic, Public
Health Institute of Federation of
Bosnia and Herzegovina, Bosnia and
Herzegovina
*Correspondence:
João Joaquim Breda, UN City,
Marmorvej 51, 2100 Copenhagen,
Denmark
e-mail: jbr@euro.who.int
With the worldwide consumption of energy drinks increasing in recent years, concerns
have been raised both in the scientific community and among the general public about the
health effects of these products. Recent studies provide data on consumption patterns in
Europe; however, more research is needed to determine the potential for adverse health
effects related to the increasing consumption of energy drinks, particularly among young
people. A review of the literature was conducted to identify published articles that exam-
ined the health risks, consequences, and policies related to energy drink consumption.The
health risks associated with energy drink consumption are primarily related to their caffeine
content, but more research is needed that evaluates the long-term effects of consuming
common energy drink ingredients. The evidence indicating adverse health effects due to
the consumption of energy drinks with alcohol is growing.The risks of heavy consumption
of energy drinks among young people have largely gone unaddressed and are poised to
become a significant public health problem in the future.
Keywords: energy drinks, Europe, consumption, review, risks, health effects, policy
INTRODUCTION
In 2006, almost 500 new brands of energy drinks were released
worldwide (1). The energy drink industry is booming, with sales
of energy drinks estimated to be over 12.5 billion USD in 2012,
an increase of 60% from 2008 to 2012 (2). Energy drinks are rel-
atively new to the wider soft drinks market, with the first energy
drink launched in Japan in 1960. Energy drinks first appeared in
Europe in 1987 before quickly expanding throughout the rest of
Europe and appearing in the US in 1997 (2). While no standard
definition of an “energy drink”is used in the scientific literature,it
is commonly understood to be a non-alcoholic drink that contains
caffeine (usually its main ingredient), taurine, vitamins, and some-
times a combination of other ingredients (such as guarana and
ginseng, among others), marketed for its perceived or actual ben-
efits as a stimulant, for improving performance and for increasing
energy (2).
Although energy drinks are a relatively new class of beverage,
they are quickly becoming as a central part of the partying sub-
culture, particularly among young people who commonly mix
energy drinks with alcohol (3–7). The full impact of the rise in
popularity of energy drinks has not yet been quantified, but the
aggressive marketing of energy drinks targeted at young people
combined with limited and varied regulation have created an envi-
ronment where energy drinks could pose a significant threat to
public health (1,4).
In 2011, the European Food Safety Authority (EFSA) commis-
sioned a study to gather consumption data for energy drinks in 16
countries of the European Union. They found that 68% of adoles-
cents (aged 10–18 years old), 30% of adults, and 18% of children
(<10 years old) consumed energy drinks. Among adolescents,
consumption varied from 48% in Greece to 82% in the Czech
Republic. Among children,consumption varied from 6% in Hun-
gary to 40% in the Czech Republic. The average consumption was
2 l in adolescents and 0.49 l in children (2).
With increasing consumption and an increase in the number
of reported cases of adverse health effects associated with energy
drink consumption, concerns have been raised both in the scien-
tific community and among the general public about the health
impact of these products. Despite this, there have been limited rig-
orous studies carried out in Europe on the risks associated with the
increase in energy drink consumption, particularly among young
people. The adverse health effects related to energy drink con-
sumption and over-consumption are still highly debated from
a scientific point of view (2), and this paper sets out to review
the available literature on the associated health risks and policies
related to energy drinks.
METHOD
We searched the Cochrane Library, Plos One, and PubMed for rele-
vant publications. We searched databases by using the terms energy
drinks and adverse effects in the Medical Subject Heading (MeSH)
database. The MeSH terms are part of a distinct vocabulary created
by the National Library of Medicine to index articles for MEDLINE
and PubMed that provides a consistent way to retrieve information
using different terminology. We reviewed publications retrieved
from this search and selected those that we judged to be relevant.
We reviewed articles through June 2014 and did not exclude arti-
cles based upon date of publication due to lack of literature in
this area. We also searched PubMed using a combination of the
following terms: risk, consumption, adverse health effects, policies,
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Breda et al. Energy drinks in Europe
mixed drinks, alcohol, and Europe. We included English language
articles only. An attempt was made to limit the scope of our review
to policy literature solely focused on the European region. How-
ever, due to a lack of literature, other regions were included in
the review. We also excluded all publications focused on animal
models.
RISKS ASSOCIATED WITH ENERGY DRINK CONSUMPTION
The health risks associated with energy drink consumption are
primarily related to their caffeine content. A caffeine overdose can
cause palpitations, hypertension, dieresis, central nervous system
stimulation, nausea, vomiting, marked hypocalcemia, metabolic
acidosis, convulsions (8), and, in rare cases, even death (9,10). In
adults, there is also an increased risk of arterial hypertension (11)
and Type 2 diabetes (12), as high consumption of caffeine reduces
insulin sensitivity (13). High-caffeine consumption among preg-
nant women increases the risk of late miscarriages, small for
gestational age infants, and stillbirths (14).
Although some types of coffee can have caffeine levels com-
parable to energy drinks, coffee is typically consumed hot and
consequently more slowly (4). Further, the proliferation of new
brands of energy drinks has included some brands, which con-
tain extreme caffeine levels much higher than mainstream brands
as they try to establish themselves in the market (1). In Europe,
the EFSA study showed that the estimated contribution of energy
drinks to total caffeine exposure was 43% in children, 13% in
adolescents, and 8% in adults (2). There are proven negative conse-
quences of caffeine consumption among children and adolescents,
including effects on the neurological and cardiovascular systems,
which can cause physical dependence and addiction (15).
Consumption of energy drinks among adolescents is associated
with other potentially negative health and behavioral outcomes
such as sensation seeking, use of tobacco and other harmful sub-
stances, and binge drinking and is associated with a greater risk
for depression and injuries that require medical treatment (16,
17). Recent literature has also found an increasing number of
problems with behavior modification and cognitive capabilities
in adolescents who use energy drinks (18).
Energy drink consumption may be a risk factor for alcohol
dependence even if not mixed with alcohol (19).This phenome-
non is hypothesized to be due to the neuropharmacologic effects of
caffeine increasing the tendency for addiction (4). There is also an
increased risk of obesity, due to the high-sugar content of energy
drinks (20). A study in the US showed that dental cavities can
result from the acidic pH and high-sugar content of products such
as energy drinks (21), and another study showed that consump-
tion of energy drinks can cause erosion and smear layer removal
in the teeth, leading to cervical dentin hypersensitivity (22).
While caffeine is considered the main ingredient in energy
drinks, there are often a number of other substances present.
The most common of these include guarana, taurine, glu-
curonolactone, and B vitamins (23). As the acute and long-term
effects of the combined consumption of many of these sub-
stances with caffeine are not well known, further studies are
required to examine the potential for adverse health effects from
energy drink consumption, particularly from long term, habitual
consumption (24).
RISKS ASSOCIATED WITH CONSUMPTION OF ENERGY
DRINKS AND ALCOHOL
The practice of mixing energy drinks with alcohol is on the rise
(3,25), with 71% of young adults (18–29 years old) who consume
energy drinks, mixing them with alcohol (2).
There is an increasing amount of research linking energy drink
consumption with high-risk behavior, particularly when com-
bined with alcohol. A study of US college students found that
those who reported combining energy drinks with alcohol were
more likely to experience adverse consequences due to their own
drinking compared to those who only drank alcohol. Adverse con-
sequences included: being taken advantage of or taking advantage
of someone sexually; riding with an intoxicated driver; and being
hurt or injured (3). In Australia, energy drink consumers were
more likely to have a higher breath alcohol concentration read-
ing, to pre-drink and use illicit drugs, and to have engaged in risky
behavior in the previous 3 months including involvement in a fight
or drink-driving (26). Further studies from the US found a posi-
tive association between energy drink consumption and high-risk
behaviors including marijuana use, fighting, sexual risk taking,
failure to use seatbelts, taking risks on a dare, smoking, drinking,
problems stemming from alcohol abuse,and illicit drug use (6,27,
28). Another study from the US military indicated that soldiers
who consumed energy drinks had a higher prevalence of suicidal-
ity and soldiers who combined energy drinks with alcohol had an
even higher prevalence (29).
The consumption of high amounts of caffeine contained within
energy drinks reduces drowsiness without diminishing the effects
of alcohol resulting in a state of “wide awake drunkenness,” keep-
ing the individual awake longer with the opportunity to continue
drinking (4,30). Studies have found that while the consumption
of energy drinks with alcohol significantly reduces the subjective
perceptions of some symptoms of alcohol intoxication including
impairment of motor coordination, there is no actual reduction
in the effects of the alcohol on the impairment of motor coordi-
nation, reaction time, or the breath alcohol concentration (31).
A positive attitude and perception about alcohol mixed energy
drinks also indicates higher consumption (32). Combining energy
drinks and alcohol has also been associated with increased heavy
drinking sessions and episodes of weekly drunkenness (3). A
small randomized controlled trial in the US showed that energy
drinks combined with alcohol seems to increase the motivation
to consume greater amounts of alcohol compared to the same
amount of alcohol alone (33). Research has continually shown the
harmful risks associated with mixing energy drinks and alcohol;
however, risks are still present when consuming energy drinks by
themselves.
ADVERSE EVENTS ASSOCIATED WITH ENERGY DRINK
CONSUMPTION
Adverse events resulting from energy drink consumption are gen-
erally caused by the sympathomimetic effects from an excess intake
of caffeine1(1,34). As energy drinks have not always had their own
1Even as little as 50 mg of caffeine can induce tachycardia and agitation. In overdose,
caffeine toxicity can mimic amphetamine poisoning and lead to seizures, psychosis,
cardiac arrhythmias, and, potentially but rarely, death.
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Breda et al. Energy drinks in Europe
unique tracking code in poison centers, there is a lack of informa-
tion available for studies of energy drink over-consumption and
associated adverse events (35). However, there have been a number
of case reports indicating the potential for adverse health effects
due to energy drink over-consumption.
In 2007, a man in Australia was reported to have suffered car-
diac arrest after consuming seven to eight cans of an energy drink
while taking part in vigorous physical activity (36). A Swedish
study in 2006 identified a number of cases with severe symp-
toms and a number of deaths possibly linked to energy drinks
(37). Iyadurai and Chung (38) reported on four cases in the US,
where patients presented at emergency rooms after suffering new,
adult-onset seizures and the only common finding was that all
the patients had consumed large amounts of energy drinks. Once
the patients abstained from consuming energy drinks, no further
seizures were reported. Avci et al. (39) reported another case from
the United States where a 28-year-old man consumed three 250 ml
energy drink cans, 5 h before a basketball match. After playing for
30 min, he lost consciousness, suffered from cardiac arrest, and
died 3 days later.While a causal relationship between the consump-
tion of large amounts of energy drinks and new-onset seizures
has not been confirmed, further research in this area would be
prudent.
A retrospective review of calls made to a poison information
center in Australia over a 7-year period found that 297 calls related
to caffeinated energy drink exposure were recorded,with call num-
bers increasing from 12 in 2004 to 65 in 2010. The researchers
raised the possibility that this was a significant underestimate due
to the lack of adequate coding of energy drinks by the poison center
studied and the fact that they were only able to access approx-
imately 50% of the total calls to poison information centers in
Australia (34). The National Poison Data System in United States
(NPDS) recorded 4854 calls (0.2% of total calls) related to energy
drinks over the year 2010–2011. Among the calls that led to more
severe adverse effects,39.3% involved alcohol mixed energy drinks.
In all, 68.2% of the alcohol-related cases were individuals under
the age of 20 (40). These studies demonstrate that energy drink
consumption and toxicity is an extensive and growing problem
in Australia and the United States and that a similar investigation
into the European poison centers may be necessary.
MARKETING OF ENERGY DRINKS
Marketing of energy drinks focuses on their stimulant effects and
perceived benefits such as increased performance, attention, sta-
mina, and weight loss, which remain unproven (1). Energy drink
advertising targets young males with a focus on promoting the
psychoactive, performance-enhancing, and stimulant effects of
energy drinks. The marketing of some brands even attempt to
glorify drug use (1) with one brand going as far as advertising
itself as “the legal alternative” to cocaine (41). Further, a study
found that self-reported measures of masculinity and risk tak-
ing behaviors were positively associated with frequency of energy
drink consumption (28). In 2010, the Food and Drug Administra-
tion of the US announced that caffeine was unsafe for use as an
additive to alcoholic beverages and the Federal Trade Commission
notified manufacturers that they were potentially engaged in the
illegal marketing of unsafe alcoholic drinks (4).
Marketing campaigns that focus on improved performance, as
well as a target market of children and adolescents and inadequate
labeling, can increase the risk of caffeine intoxication from energy
drink consumption (1). The aggressive marketing of energy drinks
and the association of some brands with athletes and sporting
events has led to many athletes consuming energy drinks before
competitions to improve performance (42) or to recover expended
energy after competition (5). In Europe,a study found that 41% of
adolescents consumed energy drinks for physical activity purposes
(2). Excessive caffeine consumption combined with strenuous
physical activity can be dangerous (36), and the association of
energy drinks with sports performance should be reconsidered.
EXISTING POLICIES
Several countries have enacted measures to regulate the label-
ing, distribution, and sale of energy drinks that contain signifi-
cant amounts of caffeine. Since 2004, European regulations have
enforced additional caffeine labeling for energy drinks that contain
at least 150 mg/l of caffeine (43). From 2014, these will be strength-
ened to ensure that all beverages with high-caffeine content or with
caffeine added for its physiological effects will be labeled with the
statement “High caffeine content. Not recommended for children
or pregnant or breast-feeding women,” followed by the caffeine
content expressed in mg/100ml (2).
Concerns about the risks of excessive caffeine consumption
previously led to outright bans on energy drinks in Denmark,
Turkey, Norway, Uruguay, Iceland, and France (5), although the
French government reluctantly removed its ban in 2008 follow-
ing an assessment by EFSA, which found no definitive safety risk,
taurine-related or not (44). Energy drinks can currently be sold
in all EU Member States, although some national legislators have
decided to take a more specific regulatory approach, including by
setting rules for sales to minors. In Sweden, for example, sales
of some products are restricted to pharmacies and sales to chil-
dren (<15 years) are banned. Canada enforces warning labels that
specify maximum daily consumption and include warnings about
mixing energy drinks with alcohol (45). In Australia and New
Zealand, energy drink manufacturers have previously bypassed
regulations by classifying products as a “dietary supplement” to
avoid caffeine limits of 80 mg/250 ml can (44). Finally, a “public
health tax” was adopted in Hungary in 2012 that applies to caf-
feinated energy drinks, in addition to a range of other products
and nutrients. The tax is levied on drinks containing >1 mg of
methylxanthines or >100 mg of taurine per 100 ml at a rate of
approximately C0.81/l (46). Energy drinks in developed countries
remain largely unregulated (5), partially because of the long term
and widespread consumption of beverages such as coffee and tea
in which caffeine is a natural constituent (1).
RECOMMENDED POLICIES
This review of the published literature on energy drinks identifies
a number of policies that might be considered by policy makers
as they move to minimize the potential for harmful effects from
energy drink consumption.
There should be an evidence-based, upper limit for the amount
of caffeine allowed in a single serving of any drink (4). While the
majority of energy drinks that control the market do not contain
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Breda et al. Energy drinks in Europe
excessive amounts of caffeine, there are an increasing number of
energy drinks entering the market that have caffeine concentra-
tions well above those of mainstream energy drinks (47). Setting
a maximum limit for caffeine per serving of any energy drink
throughout Europe could remove the extreme, highly caffeinated
energy drinks from stores and protect the public’s health (47).
The restriction of sales to children and adolescents should be
considered due to the potentially harmful adverse and develop-
mental effects of caffeine on children (15). Health practitioners
also need to be aware of the potentially dangerous consequences
of excess caffeine consumption. Policies should ensure that health-
care providers are equipped to educate families and children
at risk on the potential consequences of excessive energy drink
consumption and recognize the features of caffeine intoxication,
withdrawal, and dependence (1). Diet and substance-use histories
in primary health care should include screening for dangerous
energy drink consumption, both alone and with alcohol (3,12).
Energy drink manufacturers aggressively market their products
to children, adolescents,and young adults. The absence of regula-
tory oversight in many countries has contributed to the aggressive
marketing of energy drinks targeted primarily toward young males
(1). Regulatory agencies should enforce industry-wide standards
for responsible marketing of energy drinks and ensure that the
risks associated with energy drink consumption are well known.
FUTURE RESEARCH
There is an on-going need for further research on the possible
adverse effects of energy drink consumption in Europe. A harmo-
nized approach is vital for data matching, which could lead to new
findings about population groups that may be particularly at risk
for adverse outcomes due to energy drink consumption. Further
research is required to determine whether there is a causal link
between energy drink consumption and adult-onset seizures (38).
A number of studies have shown that energy drink consump-
tion is very high among adolescents and increasing among children
(2,12). More researchis required to characterize the effects of long-
term energy drink consumption, particularly among children and
young adults, as well as the suitability of restriction options before
widespread bans are put in place (44). Other areas of investiga-
tion related to children and adolescents include the contribution
of energy drinks to the childhood obesity epidemic, psychiatric
illness including attention deficit/hyperactivity disorder,as well as
insomnia (48).
More research is needed that focuses on the practice of mixing
alcohol with energy drinks in Europe, particularly among young
people. The potential risk for injury or excessive intoxication in
young people who consume energy drinks with alcohol is sig-
nificant. More data are needed to determine the risk of alcohol
poisoning as a result of consuming energy drinks with alcohol
(4), as well as to identify the populations who are most at risk. The
identification of policies that are effective in reducing the incidence
of adverse events at the national level could ensure the successful
implementation of similar policies in neighboring countries.
CONCLUSION
From a review of the literature, it would appear that concerns
in the scientific community and among the public regarding the
potential adverse health effects of the increased consumption of
energy drinks are broadly valid. The potential for acute caffeine
toxicity due to consumption of energy drinks may be greater
than other dietary sources of caffeine due to the variable and
sometimes very high-caffeine content of energy drinks, in combi-
nation with the aggressive marketing to young and inexperienced
consumers (1).
The potential health risks related to heavy consumption of these
products have largely gone unaddressed. Furthermore,new devel-
opments in marketing are also aimed at increasing the perceived
health functionality of energy drinks in order to gain acceptance
in an increasingly health-driven society (47,49,50). As energy
drink sales are rarely regulated by age, like alcohol and tobacco,
and there is a proven negative effect of caffeine on children, there
is the potential for a significant public health problem in future. To
date, policy development has been limited. Where policies exist,
they are yet to be systematically evaluated in terms of their impact
on heavy energy drink consumption, particularly among children
and young adults. From a cautionary viewpoint, further research
and policy action is necessary to minimize the risk of harm from
heavy and long-term energy drink consumption.
ACKNOWLEDGMENTS
João Joaquim Breda is a staff member of the World Health Organi-
zation Regional Office for Europe. Marge Reinap is a staff member
of the WHO Country Office for Estonia. The authors are respon-
sible for the views expressed in this publication and they do not
necessarily represent the decisions or stated policy of WHO.
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Conflict of Interest Statement: The authors declare that the researchwas conducted
in the absence of any commercial or financial relationships that could be construed
as a potential conflict of interest.
Received: 16 July 2014; accepted: 20 August 2014; published online: 14 October 2014.
Citation: Breda JJ, Whiting SH, Encarnação R, Norberg S, Jones R, Reinap M
and Jewell J (2014) Energy drink consumption in Europe: a review of the risks,
adverse health effects, and policy options to respond. Front. Public Health 2:134. doi:
10.3389/fpubh.2014.00134
This article was submitted to Public Health Education and Promotion, a section of the
journal Frontiers in Public Health.
Copyright © 2014 Breda , Whiting, Encarnação, Norberg , Jones, Reinap and Jewell .
This is an open-access article distributed under the terms of the Creative Commons
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