Alcohol Demand and Supersized Alcopop Consumption among Undergraduate College Students

Abstract

Supersized alcopops are sugar-sweetened beverages with extraordinarily high alcohol content; consumption is highly prevalent among college students and is associated with a variety of negative alcohol-related consequences. However, few studies have examined risk factors for consumption of these products. The objective of this study was to examine, among a college student sample, whether the behavioral economic principle of alcohol demand was associated with self-reported lifetime consumption of Four Loko—the most popular brand of supersized alcopop among underage drinkers. Participants were 170 undergraduate students who were at least 18 years of age and reported at least 1 day of alcohol consumption within the past month. Study participants completed a self-administered questionnaire assessing demographics, Four Loko consumption and associated problems, and alcohol demand (using the Brief Assessment of Alcohol Demand). Hierarchical logistic regression analyses revealed that intensity (drinks they would consume if free) significantly predicted Four Loko consumption but not breakpoint (maximum expenditure per drink) or O_max (maximum expenditure for all drinks). Findings support that students who prefer consuming large quantities of alcohol when it is free are more likely to have consumed Four Loko. Interventions increasing price or reducing the availability of Four Loko may be especially protective for this at-risk population.

Supersized alcopops, such as Four Loko, are described as large single-serve “ready-to-drink” products that combine alcohol with sugar and sweet fruit flavorings (Rossheim, Thombs, & Treffers, 2018, p. 414). These products are characterized by their high alcohol content (approximately five standard alcoholic drinks) and sweet flavor that masks the taste of alcohol (Rossheim & Thombs, 2018). It is therefore not surprising that they are commonly consumed by underage drinkers. In a national study, 9% of underage drinkers consumed supersized alcopops within the past 30 days, and 6% consumed Four Loko within the past 30 days, making Four Loko the most commonly consumed brand of supersized alcopops among underage drinkers (Fortunato et al., 2014). Further, in a recent study of undergraduate college student drinkers in three states, 46% had consumed Four Loko, and among consumers, 93% first drank the product prior to age 21 (Rossheim, Greene, et al., 2019). This is concerning because consumption of supersized alcopops is associated with increased odds of binge drinking and alcohol-related injury among underage youth (Albers et al., 2015). Moreover, a large proportion of young people who consume an entire can or more black out (36%) and/or vomit (21%; Rossheim, Greene, et al., 2019). A better understanding of the determinants of supersized alcopop consumption is necessary for the development of effective prevention efforts. Previous research has suggested that their low cost, high alcohol content, easy accessibility, and youth-oriented marketing are factors contributing to high rates of consumption among young people (DiLoreto et al., 2012; Mart, 2011; Rossheim & Thombs, 2013; Rossheim, Thombs, et al., 2019; Rossheim, Thombs, Wagenaar, Xuan, & Aryal, 2015). It is important to note that research has shown that Four Loko is among the least expensive ready-to-drink alcohol (per gram of ethanol) available on the retail market; roughly one half the average price of beer and other flavored alcoholic beverages (DiLoreto et al., 2012; Rossheim, Thombs, et al., 2019). However, little research has examined individual-level differences in self-reported consumption of these products.

Assessing the behavioral economic principle of alcohol demand can help provide some insight regarding one of the potential motivations for supersized alcopop consumption: its low retail price. An individual’s demand reflects their relative degree of preference for a product (such as alcohol) and refers to the influence of price on that person’s willingness to purchase and consume it (Bickel, Marsch, & Carroll, 2000). Elevated alcohol demand indicates a stronger and more persistent motivation to drink (Bickel & Vuchinich, 2000; Hursh & Silberberg, 2008; Johnson & Bickel, 2006) and is associated with increased consumption, experience of negative alcohol-related consequences, and severity of alcohol misuse and other related harms (MacKillop, 2016; Morris et al., 2018; Murphy & MacKillop, 2006; Yurasek, Murphy, Clawson, Dennhardt, & MacKillop, 2013). Despite this known association with general alcohol use severity, demand has yet to be examined in relation to supersized alcopop consumption. Hence, the purpose of the current study was to examine whether alcohol demand is associated with likelihood of supersized alcopop consumption among college student drinkers. We hypothesized that undergraduate students with higher levels of demand (as measured by the Brief Assessment of Alcohol Demand [BAAD]; Owens, Murphy, & MacKillop, 2015) would be more likely to report lifetime consumption of a popular supersized alcopop product (i.e., Four Loko). Consumption of Four Loko was specifically assessed because research on retail availability (Rossheim et al., 2015) and youth consumption (Fortunato et al., 2014) of supersized alcopops suggests that Four Loko is, by far, the most popular U.S. brand. Moreover, because young people have such strong preferences for specific alcohol brands, there is a notable movement toward the assessment of brand-specific associations, especially regarding associations between alcohol marketing and consumption (Roberts et al., 2016).

Method

Participants and Procedure

Data for this study were collected as part of a larger research project examining alcohol consumption among college students (Rossheim, Greene, et al., 2019; Rossheim, Yurasek, et al., 2019). Participants were 170 undergraduate college students (66.5% female; 78.8% White) who were at least 18 years of age (M 19.96, SD 1.64) and reported at least 1 day of drinking within the past month. The majority of the sample reported having one–two (41%) or three–four (39%) drinks during a typical drinking day in the past year, with approximately 15% reporting monthly consumption of six or more drinks on a typical day in the past year. Individuals were recruited through on-campus undergraduate summer classes at a large public university and voluntarily completed an in-person survey. All procedures were approved by the university’s Institutional Review Board.

Measures

Demographic information.

Participants provided information regarding their age, discretionary income, biological sex, and race and ethnicity.

Alcohol use.

To determine current alcohol consumption, we asked participants, “During the past 30 days, on how many days did you have at least one drink of alcohol?” Response options included (a) 0 days (b) 1 or 2 days (c) 3 to 5 days (d) 6 to 9 days (e) 10 to 19 days (f) 20 to 29 days and (g) all 30 days. Participants who reported at least 1 day of drinking within the past 30 days were considered current drinkers and included in the study sample. Participants were also asked the number of drinks consumed on a typical drinking day in the past year (response options ranged from 0 to 10) and frequency of consuming six or more drinks in the past year (response options ranged from never to daily/almost daily).

Four Loko consumption.

Lifetime Four Loko use was assessed by asking participants, “Have you ever consumed Four Loko before?” Participants provided a dichotomous response (yes = 1, no = 0). To improve their understanding of the question and aid recall, we provided participants with an empty 23.5-oz. can of Four Loko to view while completing the survey.

Alcohol demand.

Alcohol demand was assessed using the BAAD (Owens et al., 2015), an abbreviated version of the original Alcohol Purchase Task (APT; Jacobs & Bickel, 1999; Murphy, MacKillop, Skidmore, & Pederson, 2009). The BAAD contains three items, each of which correspond to important demand curve components, including intensity, breakpoint, and O_max values. This alcohol demand assessment began with the following instructions:

Imagine that you and your friends are at a party on a Thursday night from 9:00 PM until 2:00 AM to see a band. Imagine that you do not have any obligations the next day (i.e., no work or classes). The following questions ask how many drinks you would purchase at various prices. The available drinks are standard size domestic beers (12 oz.), wine (5 oz.), shots of hard liquor (1.5 oz.), or mixed drinks containing one shot of liquor. Assume that you did not drink alcohol or use drugs before you went to the party, and that you will not drink or use drugs after leaving the party. Assume that the alcohol you are about to purchase is for your consumption only during the party (you cannot sell or bring the drinks home). Please respond to these questions honestly, as if you were actually in this situation.

Intensity conveys the number of drinks participants would consume if they were free and was assessed by asking, “If drinks were free, how many drinks would you have,” with a response range of 0–10 drinks. Breakpoint refers to the highest price an individual is willing to pay for one standard alcoholic drink (i.e., 14 g of pure alcohol) and was assessed by asking, “What is the maximum you would pay for a single drink,” with a response range of $0–$20. O_max is indicative of the total monetary value a participant is willing to spend within a single drinking event and was assessed by asking, “What is the maximum total amount that you would spend on drinking in an evening (approximately),” with a response range of $0–40. The BAAD was created to minimize the time burden associated with completion of the full APT measure. Although the BAAD is more condensed than the original APT, previous studies have demonstrated its validity and accuracy in predicting alcohol use outcomes (Amlung, McCarty, Morris, Tsai, & McCarthy, 2015; Athamneh, Stein, Amlung, & Bickel, 2019; Owens et al., 2015).

Data Screening and Analysis

To reduce the impact of extreme values on the results, we adjusted and accounted for outliers. Values that surpassed 3.29 SDs above the mean were instead recorded as 1 unit above the greatest nonoutlier value, including age, intensity, O_max, and breakpoint (Tabachnick & Fidell, 2013). Bivariate tests were used to analyze the associations between demographic variables, alcohol consumption, alcohol demand, and Four Loko consumption. A hierarchical logistic regression analysis was conducted to determine associations between each alcohol demand metrics (intensity, breakpoint, O_max) and lifetime consumption of Four Loko.¹ Step 1 in this model controlled for common predictors of alcohol use (age, sex, and past month alcohol consumption). All three alcohol demand indices were then added in Step 2.

Results

Descriptive Statistics and Correlational Analyses

Overall, 52.9% (n = 90) of students reported lifetime Four Loko use (see Table 1 for descriptive statistics for the overall sample and as a function of Four Loko consumption). Pearson’s r and chi-square statistics were used to analyze bivariate associations between variables. Age was positively associated with breakpoint and O_max, whereas biological sex was associated with intensity and O_max. Discretionary income and race were not significantly related to any variables of interest and therefore not included as covariates in final analyses. Past-month alcohol consumption and Four Loko use were positively associated with intensity values but not breakpoint or O_max, and all three demand indices were strongly correlated.

Table 1.

Descriptive Statistics on Demographics, Alcohol and Demand Variables for Four Loko and Non-Four Loko Users

	Total Sample (N = 170)			Four Loko user (N = 90; 52.9%)		Non Four Loko user (N = 80; 47.1%)
Demographics/Outcome Variables	N	Mean (SD)	%	N	Mean (SD) or %	N	Mean (SD) or %
Age	170	19.96 (1.64)		90	19.93 (1.60)	80	19.99 (1.70)
Discretionary Income	164	45.70 (49.89)		86	45.03 (44.07)	78	46.44 (55.90)
Sex	170			90		80
Male	57		33.5	30	33.3%	27	33.8%
Female	113		66.5	60	66.7%	53	66.3%
Race	170			90		80
White	134		78.8	77	85.6%	57	71.3%
Black	10		5.9	4	4.40%	6	7.50%
Asian	13		7.6	5	5.60%	8	10.0%
Native	1		0.6	0	0.00%	1	1.30%
Hawaiian/Pacific
Islander
Multi-Racial	7		4.1	1	1.10%	6	7.50%
Other	5		2.9	3	3.30%	2	2.50%
Alcohol Use (no. days per month)a	170			90		80
1–2 days	60		35.3	23	25.6%	37	46.3%
3–5 days	52		30.6	29	32.2%	23	28.7%
6–9 days	38		22.4	23	25.6%	15	18.8%
10–19 days	18		10.6	13	14.4%	5	6.3%
20–29 days	2		1.20	2	2.20%	0	0.00%
All 30 days	0		0.00	0	0.00%	0	0.00%
Intensity	170	4.61 (2.30)		90	5.17 (2.23)	80	3.98 (2.21)
Omax	170	20.38 (9.02)		90	21.29 (8.87)	80	19.35 (9.12)
Breakpointb	170	6.05 (2.50)		90	6.10 (2.56)	80	6.00 (2.44)

Note. max = maximum (in O_max, which indicates the maximum expenditure for all drinks).

^aChi-square analyses revealed a significant association between past month alcohol consumption and lifetime Four Loko consumption ꭓ² (4) = 10.65, p < .05 indicating that Four Loko users were more likely to report consuming alcohol in the categories ranging from 3 to 29 days in the past month compared to non-Four Loko users, who were more likely to report consuming alcohol 1–2 days in the past month.

^bMaximum expenditure per drink.

^*p < .01

Primary Analyses

To determine whether higher demand for alcohol was associated with Four Loko consumption, we constructed a hierarchical logistic regression model, adjusting for relevant covariates. Statistical significance of the overall model and an assessment of residual plots both suggested good model fit, χ² (9, N = 170) = 19.32, p < .05, Nagelkerke’s R² = .14. Intensity, but not breakpoint or O_max, was a significant predictor. Specifically, each unit increase in intensity value was associated with 1.26 times the odds of reporting lifetime use of Four Loko (p = .02; 95% confidence interval [1.05, 1.52]; see Table 2 for logistic regression model).²

Table 2.

Logistic Regression Models Examining Associations Between Alcohol Demand and Four Loko Consumption.

Variable			95% CI
	b	AOR	Lower	Upper	p
Step 1
Age	.004	1.00	0.82	1.23	.967
Female	0.36	1.43	0.69	2.96	.340
Alcohol Consumption (no. days per month)a
1–2 days (ref)	ref	ref	ref	ref	.389
3–5 days	0.64	1.90	0.87	4.14	.109
6–9 days	0.67	1.96	0.82	4.67	.129
10–19 days	0.93	2.49	0.73	8.55	.147
Step 2
Intensity	0.23	1.26	1.05	1.52	.015*
Omax	−0.00	1.00	0.95	1.05	.956
Break pointb	−0.02	0.98	0.84	1.14	.801

Note. AOR = adjusted odds ratio; CI = confidence interval; max = maximum (in O_max, which indicates the maximum expenditure for all drinks).

^aDue to low endorsement rates, consuming alcohol 20–29 days (n = 2) and all 30 days (n = 0) were removed.

^bMaximum expenditure per drink.

^*p ≤ .05

Discussion

The purpose of this study was to examine whether individual alcohol demand (specifically intensity, breakpoint, and O_max) was associated with self-reported lifetime consumption of Four Loko in a college student sample. Results indicated that undergraduate students who reported higher hypothetical consumption of alcohol when it was free (intensity) were more likely to report consuming Four Loko. Specifically, each additional drink the participant would hypothetically consume when alcohol was provided for free was associated with a 26% increase in the odds of having consumed Four Loko in their lifetime. Breakpoint and O_max, however, were not associated with Four Loko use. These results extend previous research by identifying an important individual risk factor for Four Loko consumption among college drinkers. Specifically, students with a tendency to consume large quantities of alcohol when it is available at very low prices are more likely to have consumed Four Loko. Hence, students with a propensity for consuming large quantities of alcohol may be drawn to Four Loko because of its high alcohol content and low price. Moreover, the availability of supersized alcopops may facilitate heavy drinking among this especially at-risk group. It is important to note that these effects were present after controlling for drinking days and sex, suggesting the decision to consume Four Loko is not merely a product of overall heavier drinking behaviors.

The lack of significant associations between breakpoint or O_max and Four Loko consumption suggests that although Four Loko consumers have higher demand, this is specific to situations where drinks are free or cheap. Breakpoint and O_max are indices related to maximum expenditure and price sensitivity, rather than unrestrained consumption like intensity. The average intensity for the overall sample (4.6 standard drinks) suggests that many students will consume dangerous quantities of alcohol when it is available for free. This may reflect the nature of our study sample, which included a large number of students under the age of 21 (n = 115) who may have preferred to drink primarily in situations where alcohol was free or inexpensive due to limited financial resources (McDaniel, Montalto, & Ashton, 2014). Because of this price sensitivity, Four Loko consumers may be responsive to, and therefore most protected by, prevention efforts aimed at increasing the price and/or decreasing the alcohol content of Four Loko products (Rossheim et al., 2018; Rossheim, Thombs, et al., 2019; Toomey, Lenk, & Wagenaar, 2007).

Study findings should be considered with the following six limitations. First, this study relied on a sample of college students from a single university, so caution should be used in generalizing results to other populations. Second, the cross-sectional nature of the study did not allow for a causal inferences to be made. For example, it is unclear whether alcohol demand was a precipitating factor for Four Loko consumption and/or prior experience consuming Four Loko may have shaped current demand for alcohol. Regardless of directionality, the current study identifies a particularly at-risk group of drinkers who have previous experience consuming Four Loko and a propensity to drink large quantities of alcohol when it is available for a very low price. However, longitudinal studies are needed to further explore this association. Third, we examined only the association between alcohol demand and one supersized alcopop brand (e.g., Four Loko), which may limit the ability to generalize study findings to all alcopop products. Given the recent movement toward using brand-specific measures for assessing alcohol consumption and associated factors (Roberts et al., 2016), the focus on Four Loko—the most widely available and consumed brand—as well as the use of physical cans to aid recall during the surveys could both be viewed as notable study strengths. Regardless, future research in this area may want to examine these associations with other brands of supersized alcopops. Fourth, we did not assess for levels of craving or cue reactivity, which may have been elicited by providing participants with an empty can of Four Loko. Fifth, although the BAAD has been found to be a valid measure of alcohol demand (Athamneh et al., 2019; Owens et al., 2015), it assesses only three demand indices and does not include the measurement of Pmax (price associated with O_max) or elasticity (rate of change in consumption with changes in price). Moreover, elasticity is arguably one of the strongest predictors of substance use severity (Hursh & Silberberg, 2008). As a result, future studies should examine Four Loko consumption using the full APT measure. Sixth, lifetime use of Four Loko was assessed using a single, dichotomous question (yes or no). Studies examining a broader range of frequency and quantity of consumption are needed.

Despite these limitations, our results have several important public health implications. Four Loko is currently among the least expensive ready-to-drink alcohol available on the market (DiLoreto et al., 2012; Rossheim, Thombs, et al., 2019). Similarly, Four Loko is sold in a broad range of stores throughout most states and is most commonly available at gas stations and convenience stores (Rossheim et al., 2015; Rossheim, Thombs, et al., 2019). The low retail cost in combination with the widespread availability of these products appears to contribute to the ease with which underage drinkers are able to obtain and consume these products (Rossheim, Greene, et al., 2019). Our finding that Four Loko consumers are prone to drinking more heavily than are their peers when alcohol is available at very low prices supports the notion that supersized alcopops facilitate the heavy consumption of alcohol. These findings support that interventions raising the retail price and restricting the total alcohol content of these products (which would also likely increase price per gram of ethanol; Rossheim, Thombs, et al., 2019) could reduce heavy consumption by this at-risk population prone to heavy consumption at low prices (Rossheim et al., 2018).