Abstract
Aims:
This study aimed to examine and compare the use of energy drinks, over-the-counter (OTC) painkillers and misuse of prescription drugs in two cohorts of Norwegian adolescents entering high school (i.e. grade 11) immediately prior to and during the initial year of the COVID-19 pandemic.
Methods:
Accelerated longitudinal design and multi-cohort sampling enabled identification of the two socio-demographically comparable cohorts of grade 11 students: (a) COVID-19 cohort assessed in the autumn of 2020 (n=915) and (b) pre-COVID-19 cohort assessed in the autumn of 2018/19 (n=1621). Unadjusted and adjusted logistic and Poisson models were used to estimate the proportion of (mis)users and use frequencies among (mis)users in two cohorts.
Results:
Energy drinks use was both more common in the COVID-19 cohort (60.8% vs. 52.5%; adjusted odds ratio=1.40, 95% confidence interval (CI) 1.18–1.66, p<0.001) and more frequent among users from this cohort than among their pre-COVID-19 counterparts (9.58 vs. 7.79 days past month, adjusted incidence risk ratio (aIRR)=1.23, 95% CI 1.14–1.32, p<0.001). No cohort differences were observed in OTC painkillers use. Prescription drugs misuse was equally common in the two cohorts but was more frequent among misusers from the COVID-19 cohort than among their pre-COVID-19 counterparts (18.94 vs. 12.45 times past year, aIRR=1.52, 95% CI 1.10–2.10, p<0.001).
Conclusions:
Norwegian adolescents from the COVID-19 cohort were more likely to use energy drinks and, once engaged in these behaviours, to use energy drinks and misuse prescription drugs more frequently than their pre-COVID-19 counterparts.
Keywords: COVID-19, adolescents, energy drinks, painkillers, prescription drugs, substance use
Introduction
In response to the COVID-19 pandemic, Norway imposed a nationwide lockdown, together with an extensive economic package in March 2020 [1]. While this strategy was ultimately evaluated as successful [2,3], the implemented measures – including the closures of all educational institutions for several months; remote work and teaching; limitations on shopping, travel, cultural and sports events; and distancing, self-isolation and quarantine measures – profoundly shaped everyday experiences of youth and their families.
Adolescent health during these conditions remains an important public health concern globally [4,5], with recent research largely focusing on adolescents’ mental health [6–10] and alcohol and cannabis use [11–13]. However, less is known about whether there may have been pandemic-related changes in use and misuse of other substances, despite the well-recognised risks and adverse consequences of energy drinks use [14–16], and over-the-counter (OTC) or prescription drugs misuse [17–21] during adolescence. We examined and compared these behaviours among Norwegian adolescents entering high school immediately prior to and during the initial pandemic year.
Methods
Study design and participants
We used data from the ongoing longitudinal MyLife study [22], which aimed to enrol all 8th, 9th and 10th graders from 33 middle schools throughout Norway. The schools were selected based on the geographic region, urbanity and standard of living [23] of the corresponding communities, resulting in a nationwide sample reflecting all regions of the country and both urban and rural communities of varied standards.
A diverse, multi-cohort sample of 3512 students from grades 8 to 10 was recruited at T1 baseline in 2017. Starting in the autumn of 2017, the students completed annual e-surveys during regular school hours while in grades 8–10 (i.e. middle school) and in their free time once in grades 11–13 (i.e. high school). The original study received approval from the Norwegian Data Protection Authority (# 15/01495) after ethical evaluation by the National Committee for Research Ethics in the Social Sciences and the Humanities (# 2016/137). Detailed study protocol, procedures and cohort descriptions are provided elsewhere [22].
Accelerated longitudinal design allowed for decoupling of data collection waves, school grades/cohorts and secular periods of interest (i.e. before and during the pandemic). Specifically, we were able to define two comparable cohorts of adolescents entering high school (i.e. grade 11) in relation to the COVID-19 conditions. The COVID-19 cohort included 915 adolescents who were grade 8 at 2017 study baseline and thus started grade 11 in the autumn of 2020. The pre-COVID-19 cohort included 1621 adolescents who were grades 9 and 10 at 2017 study baseline and thus started grade 11 in autumn 2019 and 2018, respectively. In short, because all adolescent participants were originally recruited from the same 33 schools when they were either grade 8, 9 or 10 in 2017, our resulting cohorts were by design socio-demographically comparable except for the COVID-19 period. Identical methodology was utilised in previous reports from these data to examine putative differences in adolescent adjustment related to the COVID-19 conditions [8,13].
Measures
Outcomes
Students reported how often they had consumed energy drinks (e.g. Battery, Red Bull, etc.) or used OTC painkillers (e.g. ibuprofen, paracetamol, etc.) in the past 30 days. The original response categories were recoded into the number of days used (i.e. ‘two or three days a week’ = 10 days a month).
Next, students reported how often they used prescription medications that were (a) not their own or (b) in amounts or time periods greater than those prescribed to them by a doctor in the past 12 months. The original response categories were recoded into counts (i.e. ‘six to 10 times in the past year’ = eight times). The responses both items were summed up to capture the number of prescription drugs misuse occasions in the past year.
Covariates
We included sex, parental cohabitation and the language spoken at home (as a proxy for immigrant background) as reported by students at the T1 2017 baseline; subjective social status as reported by students on the MacArthur Scale of Subjective Social Status [24] and averaged across T1 and T2 (2017–18) reports; and currently experienced negative life events (NLE) as reported at grade 11 assessment [25].
Analyses
Missing values on all covariates were classified and analysed as the ‘unknown’ category to prevent data loss. Missing values on outcome variables were not imputed. Unadjusted and adjusted logistic and Poisson models were used to estimate and examine (a) the proportion of (mis)users and b) the frequencies of use among (mis)users in two cohorts. All analyses were conducted in Stata v15 (StataCorp, College Station, TX) and accounted for school-level nesting with cluster robust standard errors in all regression models. Corresponding predicted probabilities and counts were obtained using the –margins command and were estimated at the average values of the remaining covariates.
Results
Cohort characteristics are shown in Table I. The results from all unadjusted (model 0) and adjusted (model 1) models are shown in Table II.
Table I.
Sample characteristics at grade 11 assessment, N=2536.
| Study variables | Pre-COVID-19 cohort | COVID-19 cohort |
|---|---|---|
| Grade 11 entry in autumn 2018–2019 | Grade 11 entry in autumn 2020 | |
| N=1621 | N=915 | |
| Covariates | ||
| Sex, n (%) | ||
| Boy | 669 (41.3%) | 362 (39.6%) |
| Girl | 952 (58.7%) | 553 (60.4%) |
| Parental cohabitation, n (%) | ||
| Yes | 988 (60.9%) | 609 (66.6%) |
| No | 384 (23.7%) | 212 (23.2%) |
| Unknown | 249 (15.4%) | 94 (10.3%) |
| Subjective familial social status, n (%) | ||
| Low | 59 (3.6%) | 24 (2.6%) |
| Average | 857 (52.9%) | 492 (53.8%) |
| High | 646 (39.9%) | 354 (38.7%) |
| Unknown | 59 (3.6%) | 45 (4.2%) |
| Immigrant background, n (%) | ||
| No | 1210 (74.7%) | 716 (78.2%) |
| Yes | 164 (10.1%) | 103 (11.3%) |
| Unknown | 247 (15.2%) | 96 (10.5%) |
| Grade 11 NLE, M (SD) | 1.65 (1.82) | 1.74 (1.89) |
| Outcomes grade 11 | ||
| Energy drinks use past month, a n (%) | ||
| Yes | 844 (52.1%) | 547 (59.8%) |
| No | 767 (47.3%) | 367 (40.1%) |
| Unknown | 10 (0.6%) | 1 (0.1%) |
| OTC painkillers use past month, b n (%) | ||
| Yes | 875 (53.9%) | 503 (55.0%) |
| No | 735 (45.3%) | 401 (44.8%) |
| Unknown | 11 (0.7%) | 2 (0.2%) |
| Prescription drugs misuse past year, c n (%) | ||
| Yes | 206 (12.7%) | 125 (13.6%) |
| No | 1397 (86.2%) | 781 (85.4%) |
| Unknown | 18 (1.1%) | 9 (1.0%) |
Grade 11 is the first year of high school in Norway. Because school enrolment in Norway is determined by birth year, most students start high school during the calendar year when they turn 16. Our pre-COVID-19 cohort comprised adolescents who entered high school (i.e. grade 11) in the two years immediately preceding the COVID-19 pandemic; that is, during the autumn semesters of 2018 and 2019. Our COVID-19 cohort comprised adolescents who entered high school (i.e. grade 11) in the first year of the COVID-19 pandemic; that is, during the autumn semester of 2020. All covariates assessed at T1 2017 baseline, except for the subjective social status (average of T1–T2 2017–2018 assessments) and current NLE index (grade 11) assessed upon high school entry.
Unadjusted proportions of students in each cohort reporting any use of energy drinks in the past 30 days.
Unadjusted proportions of students in each cohort reporting any use of over-the-counter (OTC) painkillers in the past 30 days.
Unadjusted proportions of students in each cohort reporting any misuse in the past 12 months. This reflected using prescription drugs that weren’t one’s own or using prescribed drugs in amounts or periods that were more than prescribed by a doctor.
NLE: negative life events; OTC: over the counter.
Table II.
Use of energy drinks and OTC painkillers, and misuse of prescription drugs among grade 11 students from Norway prior to and during the initial COVID-19 year.
| Outcomes | Any use a | Use frequency among those reporting any use b | ||||
|---|---|---|---|---|---|---|
| Pre-COVID-19 cohort | COVID-19 cohort | OR (95% CI) | Pre-COVID-19 cohort | COVID-19 cohort | IRR (95% CI) | |
| Grade 11 entry in autumn 2018/2019 | Grade 11 entry autumn 2020 | Grade 11 entry in autumn 2018/2019 | Grade 11 entry in autumn 2020 | |||
| Energy drinks use past month | ||||||
| Model 0: unadjusted | 52.4% | 59.8% | 1.35 (1.17–1.56)*** | 7.87 (0.19) | 9.60 (0.23) | 1.22 (1.13–1.31)*** |
| Model 1: covariates | 52.5% | 60.8% | 1.40 (1.18–1.66)*** | 7.79 (0.19) | 9.58 (0.21) | 1.23 (1.14–1.32)*** |
| OTC painkillers use past month | ||||||
| Model 0: unadjusted | 54.3% | 55.1% | 1.03 (0.87–1.21) | 6.65 (0.14) | 6.68 (.16) | 1.03 (.95 – 1.06) |
| Model 1: covariates | 55.1% | 55.0% | 0.99 (0.82–1.21) | 6.61 (0.13) | 6.55 (.16) | .99 (.93 – 1.05) |
| Prescription drugs misuse past year c | ||||||
| Model 0: unadjusted | 12.9% | 13.7% | 1.09 (0.88–1.33) | 13.32 (1.46) | 19.13 (2.25) | 1.44 (1.10–1.88)** |
| Model 1: covariates | 11.8% | 12.3% | 1.05 (0.84–1.30) | 12.45 (1.55) | 18.94 (2.21) | 1.52 (1.10–2.10)** |
Our pre-COVID-19 cohort comprised adolescents who entered high school (i.e. grade 11) in the two years immediately preceding the COVID-19 pandemic; that is, during the autumn semesters of 2018 and 2019. Our COVID-19 cohort comprised adolescents who entered high school (i.e. grade 11) in the first year of the COVID-19 pandemic; that is, during the autumn semester of 2020. Model 0: accounted for school nesting; analytical samples varied as a function of valid responses on outcome variables. Model 1: accounted for school nesting, and adjusted for sex, parental cohabitation and immigrant background, and current NLE index as reported at grade 11 at high school entry.
Results from the logistic regression models, including the odds ratio estimates (OR) with corresponding 95% CI and estimated proportions for each cohort.
Shown are the results from the Poisson regression models, including IRR estimates with corresponding 95% CI and estimated marginal means (i.e. counts) for each cohort. This reflected the number of days during the past month for energy drinks and OTC painkillers use and the number of occasions during past year for prescription drugs misuse.
Prescription drugs misuse reflected the use of medications that weren’t one’s own or in amounts and periods that were more than prescribed by a doctor.
p⩽0.05; **p⩽0.01; ***p⩽0.001.
OR: odds ratio; CI: confidence interval; IRR: incidence risk ratio.
Past-month use of energy drinks was both more common in the COVID-19 cohort (60.8% vs. 52.5%; aORModel1=1.40, 95% confidence interval (CI) 1.18–1.66) and more frequent among users from this cohort than among their pre-COVID peers (adjusted incidence risk ratio (aIRR)Model1=1.23, 95% CI 1.14–1.32), with a differential of almost two days per month (9.58 vs. 7.79 days; absolute difference=1.79).
No cohort differences were observed for the past-month use of OTC painkillers, either in the proportion of users or in use frequencies among users.
Past-year misuse of prescription drugs was equally common in the two cohorts but was more frequent among misusers from the COVID-19 cohort than among their pre-COVID-19 peers (18.94 vs. 12.45 times in the past year, aIRRModel1=1.52, 95% CI 1.10–2.10, p<0.001), with a differential of more than six misuse occasions per year (18.94 vs. 12.45; absolute difference=6.49).
Discussion
This is the first study to explore the use of energy drinks and OTC painkillers and the misuse of prescription drugs before and during the early COVID-19 pandemic among adolescents entering high school in Norway. Adolescents from the COVID-19 cohort were more likely to use energy drinks and, once engaged in these behaviours, to use energy drinks and misuse prescription drugs more frequently than their pre-COVID-19 counterparts. Of particular concern may be an excess of six occasions of prescription drugs misuse among the COVID-19 cohort misusers.
While other factors may have driven these trends [26], we believe that the observed differences can be primarily attributed to the COVID-19 conditions. First, these two socio-demographically matched adolescent cohorts were separated only by one calendar year, but it was a year marked by the pandemic and pandemic-curbing measures. Further, no differences were observed in the use of OTC painkillers, but only in behaviours that have been suggested as coping mechanisms for pandemic-related stress [27]. As energy drinks use and prescriptions drugs misuse are unhealthy adolescent behaviours by themselves, as well as potent risk factors for subsequent adverse outcomes [14,15,17–19], these results are of public health significance and of relevance for strategies aiming to mitigate the pandemic effects among youth.
These results should be understood within the specific socio-political context of the pandemic response in Norway [1–3]. It is also likely that the observed effects are conservative, given the relatively short-term follow-up (eight to 10 months into the pandemic) and the non-participation of schools from Oslo, which was disproportionally affected by the pandemic. Given our sample characteristics and study design, these results should be considered exploratory and not as the national prevalence estimates. Examination of these behaviours over longer time periods and across various sub-populations (i.e. sex) is essential [28].
Footnotes
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding: The authors received no financial support for the research, authorship and/or publication of this article.
ORCID iD: Jasmina Burdzovic Andreas 
https://orcid.org/0000-0002-6730-1321
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