Brand to ban: What young people really think about energy drinks

Posted by Professor Amelia Lake, Fuse Deputy Director; Dr Helen Moore, Fuse Associate; and Grace Stewart - Teesside University. 

Walk into any corner shop, and you’ll see them lined up in the fridge: brightly coloured cans promising energy, improved focus and even hydration. They’re everywhere online too, all over social media feeds... What are we talking about? Energy drinks. They have become a familiar part of the landscape in the UK, but particularly for young people who are consuming them in ever increasing numbers; the question is, why are they so popular, and what is being done about it?

What are energy drinks?

High-caffeine energy drinks are soft drinks that contain at least 150 milligrams (mg) of caffeine per litre of drink, which is higher than other soft drinks. Back in 2018, Jamie Oliver led a campaign that resulted in many retailers voluntarily banning sales to under-16s. Fast forward to July 2024, and the new Labour Government announced in the King’s Speech that it would restrict the sale of energy drinks to under-18s. There is currently a live Government consultation around banning the sale of high-caffeine energy drinks to children which will close on 26 November 2025. If you want to contribute, please do so.

Our research

Our mixed-method qualitative study was published in the Journal of Human Nutrition and Dietetics this week. The work was carried out in North-East England and sheds light on the reasons behind young people still consuming these drinks in large numbers, and what they, the consumers, really think could be done about it.

Our research involved:

• Focus groups with 50 students aged 9–14 years old
• A survey completed by 22 Year 9 students (aged 13–14 years old)

The aim was to understand how children and young people perceive energy drinks and hydration drinks, and to explore their consumption habits post the UK’s 2018 voluntary sales ban to under-16s. This follows on from our earlier work published in 2017.

What did we find?

• 81.8% of surveyed students (13-14 year olds) consume energy drinks, with boys drinking more frequently than girls.
• Most young people drink EDs 2-4 times a week, and many started before age 12 years.
• Taste, branding, and peer influence were major motivators.
• Corner/local shops were the most common purchase point, often with little enforcement of age restrictions.
• Hydration drinks (e.g. PRIME) are seen as healthier alternatives, though their actual health impact is still unclear.

So, why are energy drinks so popular?

Through the focus groups, we learned that young people are really clued-up about energy drinks. They talked about branding, marketing, taste, peer influence, cost, and just how easy it is to get hold of them. From YouTube ads to celebrity endorsements (think F1 and YouTubers like Logan Paul and KSI), marketing was seen as a powerful force driving consumption. One young person said:

“If I made the exact same drink, in a bottle, no one would buy it.”

Bright colours, cool designs, and slogans were all cited as reasons that young people are drawn to these products. Many of the young people taking part in the research knew that they were being targeted by the manufacturers, but they didn’t mind. In fact, some saw energy drinks as part of their identity, linked to gaming, sports, or just being “cool.”

Policy gaps and opportunities

Despite the 2018 voluntary ban mainly in supermarkets, energy drinks remain easily accessible. Many children believed there was a legal age restriction but said that they could still buy energy drinks from shops or online without ID checks. This links back to the importance of the current live consultation around Energy Drinks and sales restrictions.

This raises an important point for policymakers to consider: if energy drinks are still seen as aspirational, accessible, and part of youth culture, young people will find ways to get them, or switch to similar products that exist outside of the ban. There needs to be a wider strategy to tackle this, which means tighter regulation of marketing (anywhere that young people spend their time - including online spaces), effective, up-to-date, accurate education about the health impacts of energy drinks and the tactics used by manufacturers, and importantly including young people in this conversation.

Our research shows that young people are not passive consumers of energy drinks. They’re thoughtful, aware, and influenced by a range of social and cultural factors that need to be understood if we want to reduce energy drink consumption.

Our study had several possible interventions suggested by young people:

• Actual legislative enforcement of age restrictions.
• Changing product placement in stores (e.g., away from essentials and in areas similar to cigarettes and alcohol).
• Duller packaging and clearer health warnings.
• Wider awareness around health risks.

Why this matters

Energy drinks are linked to a range of health issues; from insomnia and anxiety to obesity and poor academic performance. Yet, their appeal among young people remains strong, driven by clever, pervasive, marketing in addition to peer influence.

Our paper highlights the urgent need for strong policy action, increased awareness, and further research in this space.

Images:

1: Photo by (Joenomias) Menno de Jong from Pixabay

2: Photo by thom masat on Unsplash (with modifications)

Intersectionality: buzzword or key to tackling health inequalities?

Posted by Dr Daniel Holman, Professor Sarah Salway, Dr Andrew Bell, University of Sheffield

Intersectionality – the idea that multiple axes of inequality overlap and interact – arguably holds great potential to understand and tackle health inequalities. But what do researchers and those working in policy and practice in this area actually think about the approach? What do they see as the key challenges and opportunities? We held a professional stakeholder workshop and consultation survey to find out. Our findings indicated a ‘cautiously optimistic’ view of an intersectional health perspective.

A growing interest in intersectionality and health

Intersectionality is currently something of a buzzword. A search of the scientific literature reveals an explosion in interest, with an eight-fold increase in papers mentioning the term in the last ten years, and a twenty-fold increase for those mentioning both ‘intersectionality’ and ‘health’:

Figure 1 - SCOPUS documents mentioning both 'intersectionality' and 'health' in title, abstract or keywords

The interest in applying intersectionality to health research, and specifically health inequalities research, has now also been fuelled by the pandemic. Ethnicity, deprivation, and age strongly influence Covid-19 outcomes. Calls for intersectional analysis of Covid-19 have now been published in BMJ Global Health and The Lancet.

Yet recent events have indicated significant political barriers. The Sewell Report essentially explained away ethnic health inequalities with reference to socioeconomic factors – anathema to intersectionality – and last year the UK Government declared itself ‘unequivocally against’ Critical Race Theory (within which intersectionality is rooted).

Further, policy-making is a process of dialogue, negotiation and ‘knowledge interaction’, with power relationships, varied sources of ‘evidence’ and competing drivers clearly at play. So, we should not expect the concept to straightforwardly impact how health inequalities are understood and addressed.

Theory vs. practice

In theory, intersectionality offers a critical, innovative approach for understanding and tackling diverse health inequalities. It essentially concerns the power structures and processes that drive these inequalities, and seeks to highlight how unjust systems of discrimination such as racism, sexism and classism operate in tandem to result in unequal, unfair life chances. The animation video below gives an overview of the approach:

 

Putting intersectionality to work entails a number of practical challenges. Many of our participants thought the term sounded like just another buzzword, questioning what it adds. Concerns were raised about the complexity of intersectionality both as a conceptual and methodological framework. For resource-strapped public health teams this was felt to be a particular barrier. Complexity can sometimes inhibit action because policy making processes support simplicity and certainty.

Methodologically, intersectionality includes a danger of over-disaggregation. Working with finer and finer categories to produce a granular picture of inequalities risks losing sight of the processes of disadvantage that impact across groups of people. Questions were also raised over how we can reveal mechanisms including discrimination, use mixed methods and participatory approaches, include marginalised populations, and access large, high quality datasets that intersectional analyses might require.

How might intersectionality actually be implemented? We asked respondents to consider two suggestions

First was the idea of using intersectionality to target and tailor interventions and policies. This raised numerous concerns that it potentially takes focus away from structural changes; assumes that all those in a particular intersection are the same; excludes those who do not fall into the targeted category, and; reinforces deficit and stigmatising narratives. Nonetheless, respondents thought that targeting could have value if marginalised groups were included in the process. They also suggested that geography should be considered when targeting as it is a key aspect of social context.

Second was the idea of monitoring and evaluating the impact of policies and programmes on different sub-groups. This approach was more popular, with participants keen to be able to demonstrate differential and unanticipated outcomes of initiatives. Again, the importance of meaningful engagement of marginalised groups and careful attention to understanding mechanisms, were highlighted.

What is the way forward? Our participants emphasised some key principles and points of action:

• Ensure a clear focus on systems of social discrimination and how they structure access to power, resources and life chances, especially via social institutions (such as schools).
• Wherever appropriate, participatory and co-productive approaches - entailing more equitable knowledge-production – should be used.
• Carefully consider complexity; arguably intersectionality’s biggest asset and challenge. What constitutes the right level of complexity and in which context? Trade-offs are inevitable.
• Develop clear methodological guidelines, possibly in the form of a toolkit, to help with implementing intersectionality, especially for non-academics with limited research resources.
• Big datasets with well measured social variables are essential.

Intersectionality holds much promise. It has the potential to help ensure that those experiencing multiple discrimination are not further disadvantaged by the Covid recovery phase. Acknowledging and addressing potential pitfalls and limitations of the approach is therefore crucial. Marginalised populations, researchers, policy and practice professionals all need to be part of the conversation.

To read more about the project from which this research originated, please take a look at the project website: http://intersectionalhealth.org

Uniting planning and health to tackle obesity

Public Heath England (PHE) has just published practical guidance, informed by Fuse research, for local authorities wanting to use the planning system to improve public health. In this blog post Andy Netherton and Michael Chang, from PHE's Healthy Places Team, tell us how they hope the guidance will be used to tackle obesity.

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Obesity is a modern day public health challenge that cannot be met by a traditional scientific approach alone. Tackling obesity levels in England requires action by national and local government, health and social care, non-governmental agencies, communities and individuals – a whole system approach.

Traditionally the vast majority of public discussion and state campaigns target individual level behaviour change and treatment. This does not address the environment in which we live, that influences the decisions and actions that we make; things such as what we eat, whether we exercise, how we travel to work, how we interact within the community and if we have access to and use open spaces.

These physical environmental factors can be influenced by national and local policy and action. State led interventions are difficult to put into place due to the need for evidence within complex social and environmental determinants. The difficulty to isolate evidence related to these interventions and local government capacity to balance competing demands results in an inconsistent approach to policy adoption.

The use of planning policy and development management is a clear example of an intervention to tackle obesity which is not yet consistently applied across the country. Practice across the country has shown a diverse range of approaches in local plans and planning appeal decisions which has taken over 10 years to develop, but is now accelerating.

Figure 1 – Charting the use of planning for healthy weight environments

This policy to implementation lag has to be seen in the context of an increasing obesity challenge, both in terms of prevalence and health inequalities.

Figure 2 – key obesity data and trends

Statistics on Obesity, Physical Activity and Diet, England, May 2019 - NHS Digital, Government Statistical Service

Is the reason down to the nature of local evidence provided or the knowledge of the individual local authority teams, planning inspectors or the wider planning regime?

This was recognised within the Childhood Obesity: a plan for action, Chapter 2. The challenges it identified, included the proliferation of fast food outlets, less active travel, limited access to green spaces and physical activity; and these factors create an environment that makes it harder for children and their families to make healthy choices, particularly in some of our most deprived areas.

The Childhood Obesity plan confirmed that local authorities have a key role in tackling this challenge and pledged support:

• to make sure that all local authorities are empowered and confident in finding what works for them, and;
• to develop resources that support local authorities who want to use their powers and provide up to date guidance and training for planning inspectors. 

In response Public Health England (PHE) has released guidance on using the planning system to promote healthy weight environments.

Previous research by PHE (Spatial Planning and Health: Getting Research into Practice (GRIP) study report) identified that local authorities would benefit from support that reduced the need for resource input, for example reduced duplication to create policy and practice. This publication is aimed at getting knowledge into action by providing guidance and a template supplementary planning document (SPD), one of many planning levers available to local authorities, that can be used by local authority planning and public health teams. It answers the following questions:

• What is the current evidence base linking the built and natural environment and healthy weight? Specifically, can the local food environment influence diet and obesity?
• How can the planning regime be used to promote healthy weight environments?

The publication identifies the background work necessary in order to comply with planning policy development, where the key is the use of local evidence and consultation. It specifically provides guidance on the use of the 400m exclusion zone for hot food takeaways, features of the built environment and building design that promotes physical activity, use of green space, allotments and neighbourhood design.

The provided supplementary planning document (SPD) is a starting point that requires local content and policy to be added. It can be used as a whole or parts selected on local need or to dovetail to existing local policies. Clearly this intervention is one intervention that must be used within a wider national and local obesity strategy.

There remain challenges to promoting a healthy food environment, for example the impact from the rise of industrial kitchens for food delivery must be monitored. Work must continue to influence the energy and compositional content of other food options and build our homes and neighbourhood to allow people to more active.

This publication provides guidance on a practical evidence based intervention that draws together several professional groups within a local authority. Gateshead Council have successfully adopted and defended on appeal, controls on hot food takeaways as part of a wider approach to tackling obesity and promoting healthy weight environments. It is hoped that for many areas working together to tackle obesity will provide confidence to further unite planning and health. It moves the debate from a deficit model of obesity to an asset based (salutatogenic*) approach to promoting healthy weight.


*Israeli-American sociologist Aaron Antonovsky coined the term "salutogenesis" to describe an approach which focuses on a positive view of wellbeing rather than a negative view of disease.

A prescription for tackling riskier drinking?

Guest post by John Mooney, Fuse associate and Senior Lecturer in Public Health, University of Sunderland.

In keeping with the ‘Dry-January’ season, John Mooney reflects on a current initiative to assess the feasibility of alcohol brief interventions in high street pharmacies…

“A man walks into a high street chemist – and asks for a paracetamol and an Alka-Seltzer…” could be the start of a very unpromising joke or sketch outline… Thankfully, it’s neither, as it more accurately depicts a very common scenario, which might represent the basis of a potentially effective setting (namely pharmacy / high street chemist shops) for health promotion messages around the health risks from alcohol misuse and / or overconsumption.

AUDIT score card collection box, with prize incentive to participate

Alcohol unit indicator diagram

Unsurprisingly perhaps, it is by now fairly well established that “alcohol brief interventions” (ABIs) - in which short well-validated questionnaires about habitual drinking patterns and consequences are linked to tailored advice and feedback - can be an effective intervention in primary care based consultations / GP practices as evidenced in the SIPS trial. Evidence for the effectiveness of such interventions however is less convincing in other settings, even those where, as in a GP consultation, health is the primary focus of the interaction. Pharmacy outlets for example might be considered an obvious parallel candidate ‘setting’ where, as in the scenario above, there may clearly have been an alcohol related context surrounding the primary reason for the person’s visit.

Indeed, in addition to over-the-counter ‘remedies’ which might be sought out after alcohol over-indulgence, there are a number of ‘indicator-prescriptions’ which could be suggestive of a more chronic / long-term damaging level of alcohol consumption (such as stomach acid suppressants or high blood pressure medications). High street chemists therefore, by virtue of their community embedded location, specialist knowledge and windows of opportunity for engagement, could theoretically present a very promising setting for ABIs. The lack of evidence of effectiveness in studies where this has been rigorously evaluated, has prompted questions as to why this might be the case. Investigators have speculated on the explanation being attributable to anything from the variable attitudes of pharmacy staff to the additional time and resource constraints associated with modern pharmacy practice. A recent Master of Pharmacy dissertation at the University of Sunderland(1) – which explored possible reasons in interviews with pharmacy staff, provided some local corroboration for these potential explanations. Interviews with participating pilot sites had also however noted the value of the awareness raising aspect of the process:

“Some patients had been drinking a bottle of wine a night and didn’t realise that it could contain 9-10 units and they were really shocked when they realised”

Other potential strengths of pharmacies as a setting for ABIs might be the now well established practice of providing support to pharmacies looking to embrace a wider health promotion role. As part of NHS England’s current ‘Promotion of Healthy Lifestyles’ programme, pharmacies are now required to participate in up to six health promotion campaigns per year(2). This generally involves the display and distribution of leaflets provided by NHS England or other collaborating institutions or stakeholders. As a result, there are usually highly visible and engaging ‘health promoting and awareness raising materials’ adorning the display areas of high street pharmacies and messages around alcohol health risks and reducing them are often a focus of such displays.

Given that the brief questionnaires and tailored advice of alcohol brief interventions is a more pro-active approach than the passive display of information, a current UK pilot feasibility study for pharmacies in several UK regions funded by Drinkaware UK, involves participants self-completing a score card that is the basis of most ABI interventions. Abbreviated as AUDIT, the Alcohol Use Disorder Identification Test, developed by the World Health Organisation(3), involves a series of questions about drinking habits and the extent to which drinking might have impacted on daily activities. Not quite ‘shock tactics’, the revelation of a score that flags up concern – can give respondents some cause for reflection – especially after the season of excess! Of course the score cards themselves have information on where respondents can seek further help and participating outlets receive training in responding to questions that might arise. Essentially the pilot aims to examine how best to integrate ABIs, as unobtrusively as possible into the day-to-day working of the pharmacy.

Not a programme lacking in ambition, the same score cards are also being distributed by trained advisors in selected participating supermarkets and other community settings across the UK, the evaluation of which is set to be complex and challenging. Ultimately the organisers hope to be able to make best practice recommendations about the most effective way to implement ABIs in pharmacies and other settings, where traditionally ‘hard to reach groups’ including working age men (a key high risk group for developing alcohol related health problems) can be more easily targeted.

AUDIT score cards with information leaflets

Indeed the current Drinkaware national campaign (‘Have a little less’) of which the above initiative is a part, will be run to coincide with 'Dry-January'. With a particular focus on working age men aged between 45-60, the message is that ‘Having a little less’ alcohol can have significant health benefits. This is in line with an emerging expert consensus around some of the potential drawbacks of an over-emphasis on one month of the year(4) and that it would be more beneficial for example to achieve three drinking free days for every week of the year. With long term trends in UK consumption still on the rise and a 44 per cent increase since 2009 in those aged 50 and over accessing alcohol treatment, all initiatives exploring innovative ways of getting the message across are to be welcomed. Don’t be too surprised therefore if you are asked about alcohol consumption the next time you collect a prescription!


Note: The Sunderland University Team who are evaluating the Drinkaware community ABI pilot comprises: Prof Jonathan Ling, Mr John Mooney (PI), Dr Zeibeda Sattar and Dr Nicola Hall. Please address any correspondence to john.mooney@sunderland.ac.uk

References:

1. Asghar S. Assessing the Feasibility and Practicality of delivering Alcohol Brief Interventions in Pharmacy Settings. MPharm Dissertation, University of Sunderland 2015/16.
2. PSNC page on promoting healthy lifestyles: http://psnc.org.uk/services-commissioning/essential-services/public-health/ 
3. PHE Guide to WHO AUDIT: https://www.alcohollearningcentre.org.uk/Topics/Latest/AUDIT-Alcohol-Use-Disorders-Identification-Test/ 
4. http://theconversation.com/dry-january-is-it-worth-giving-up-alcohol-for-a-month-51956

Photography by Eileen Robinson Art ©