Association of over the counter “hangover remedy” use with alcohol use problems and consumption patterns among young adults

Abstract

This cross-sectional study of young adults examined associations of hangover remedy use with alcohol use problems. Results suggest that ever-use of hangover remedy products was positively associated with alcohol use problem score, drinks per typical drinking day, and alcohol use disorder symptom count. Use of hangover remedies among young adults merits further scientific and regulatory attention.

hangover remedy, alcohol use problems, drinking frequency and intensity, young adults

Introduction

Alcohol-induced hangover is acollection of acute psychological and physical symptoms that can arise shortly after drinking episodes as alcohol becomes metabolized and blood alcohol concentration reaches zero (Verster et al. 2020). Hangovers are typically more severe following episodes with greater alcohol consumption (Hua et al. 2022). Consequences attributable to alcohol hangover include functional impairment of daily activities (Alford et al. 2020; Verster et al. 2020), reduced cognitive performance (Gunn et al. 2018), and negative mood (van Schrojenstein et al. 2017).

Recently, over-the-counter products marketed as hangover remedies have become available in the U.S. Some hangover remedy manufactures claim that taking their product before or during heavy drinking episodes can alleviate or prevent hangover symptoms the subsequent day. A 2019 U.S. Amazon retailer website search revealed 82 unique hangover remedy products marketed in various formulations, such as tablets, powders, drinks, transdermal patches, and gummies (Verster et al. 2021). Common primary ingredients in these products include dihydromyricetin [DHM; a flavonoid found in vine tea (Ampelopsis grossedentata)], milk thistle extract (silymarin), Nacetyl L-cysteine (NAC), vitamin B or C, or the combination of such agents (Verster et al. 2021). While these products mention disease-related claims (e.g. “cure”, “treat”, “correct”, “prevent”) in marketing materials, they are sold as over-the-counter supplements and not registered as drugs by the U.S. Food and Drug Administration and do not have substantial efficacy/safety data (Verster et al. 2021).

Young adulthood is a high-risk development period for the development of heavy drinking patterns and alcohol use disorder (AUD) symptoms (Sher and Gotham 1999; Muthen and Muthen 2000; Delker et al. 2016). Given the disease-related claims on hangover product packaging (Verster et al. 2021), young people may have positive beliefs about these products—young adults who use hangover remedies could have a higher proclivity to more frequent alcohol use and binge drinking because they may be less deterred by the threat of hangovers. As such, hangover remedy users could experience recurrent episodes of excessive drinking and may be at risk for developing AUD symptoms (Verster 2009).

This cross-sectional investigation of a cohort study of young adult past 30-day drinkers examined associations of ever-use of hangover remedies with alcohol use problems. Because alcohol problem measures reflect composites of alcohol consumption patterns and AUD symptoms, we included drinking frequency/intensity, binge drinking, and AUD symptom counts as secondary outcomes. Given that bidirectional association is plausible—frequent, binge, intensive drinking may elicit more severe hangover symptoms, thus hangover remedy products might appeal to young adults (Wechsler et al. 1994; Assanangkornchai et al. 2009), we further conducted opposite analyses—alcohol use patterns/problems predicting hangover remedy use. This study would serve as an exploratory analysis.

Methods

Study design and participants

This investigation drew data from the Happiness and Health Study (Leventhal et al. 2015), a cohort survey of behavioral health that originally recruited ninth graders from ten high schools in Los Angeles, California in 2013 and recurrently surveyed them thereafter. This study used a recent survey collection conducted in January 2021–June 2021 when respondents were young adults aged 21–24 years. Of 2207 respondents who completed the assessment, the analytic sample was restricted to 1329 young adults who reported drinking at least one full drink of alcohol in the past 30 days. We excluded 17 individuals with missing data on ever-use of hangover remedy products, leaving the final sample size of n = 1312. Respondents provided informed consent. This study was approved by the University of Southern California Institutional Review Board.

Measures

Hangover remedy use

Ever-use was measured by a survey item, “Have you ever used hangover remedy pills (e.g., DHM)?” (yes/no).

Hangover remedy perceptions

Awareness was measured by, “Have you ever heard of hangover remedy pills to prevent hangovers?” (yes/no). Beliefs were measured by, “Do you feel hangover remedy pills work?” (yes/no).

Alcohol use problems

Participants completed the alcohol use problem questions (10 items), which was scored using a modified version of the Alcohol Use Disorders Identification Test (AUDIT) (Saunders et al. 1993; Hussong et al. 2019), resulting in a continuous measure of alcohol problems (range: 0–40). The first three items that measure alcohol use frequency/intensity in our data were converted into the AUDIT scale (see Supplemental Table S1), and survey questions and response options for the remaining seven items in our data were identical to those in the AUDIT. As secondary outcomes, we used the following items: past 30-day frequency, past 30-day binge drinking frequency—days with |$\ge$|5 (born male) or |$\ge$|4 (born female) drinking consumed within a couple of hours, and past 30-day drinking intensity—drinks per typical drinking day. Response options were 0, 1–2, 3–5, 6–9, 10–19, 20–29, 30 days (frequency measures) and |$<$|1, 1–2, 3, 4, 5, 6–7, 8–9, 10+ drinks (intensity measure), and these responses were recoded into separate count outcome variables by taking the median integer within each response range [e.g. 1–2(=2), 3–5(=4), 10–19(=15), 20–29(=25), 30(=30)] (Leventhal et al. 2019). Additionally, we created a past-year AUD symptom count variable based on the total number of AUD symptoms (range: 0–7). The questions and response options for the AUD symptom count variable is presented in Supplemental Table S1. Because the alcohol use problem score includes AUD symptoms and drinking frequency/intensity in its scoring, the secondary AUD symptom count outcome permitted additional analyses to parse associations with AUD symptoms per se from those accounted for drinking frequency/intensity using covariate adjustment.

Covariates

To control for a small selection of potential confounding influences previously associated with young adult alcohol use (Cho et al. 2023), we controlled for sociodemographic factors (age, gender/sexual identity, race/ethnicity, whether currently enrolling in a degree program, current employment status, and personal financial situation; see Table 1) and depressive symptoms measured by the 10-item Center for Epidemiologic Studies Depression Scale (CESD; past-week frequency of 10 symptoms; range: 0–30) (Radloff 1991).

Table 1

Characteristics of overall study sample (N = 1312).

Variable	n	%
Ever used hangover remediesa	42	3.2
Hangover remedy perceptions
Ever heard of hangover remedy products	248	18.9
Believe hangover remedies work	110	8.6
Study covariates
Age, years	21.8 (M)	0.4 (SD)
Gender identity
Male	451	34.8
Female	797	61.4
Another gender identityb	49	3.8
Sexual identity
Heterosexual	958	75.0
Non-heterosexualc	320	25.0
Race/ethnicity
Hispanic/Latino	611	47.4
Asian	203	15.7
White	232	18.0
Another race/ethnicityd	243	18.9
Currently enrolled in a degree program	802	63.7
Currently working paid job	849	68.6
Personal financial situation: Not living comfortably	782	60.7
CESD-10 scoree	9.9 (M)	6.2 (SD)

Note. Frequencies may not sum to the total due to missing observations; M = mean; SD = standard deviation.

^aEver-use of hangover remedy pills (e.g. dihydromyricetin).

^bTransgender, gender variant/non-binary, additional gender category/identity, or prefer not to disclose.

^cAsexual, bisexual, gay, lesbian, pansexual, queer, questioning/unsure, or another identity.

^dAmerican Indian, Alaska Native, Black/African American, Native Hawaiian, or Pacific Islander.

^eCenter for Epidemiologic Studies Depression Scale 10-item version (range: 0–30).

Statistical analysis

After descriptive analyses, the primary analysis used linear regressions assessing associations of hangover remedy ever-use with alcohol use problem scores. For secondary outcomes, a series of negative binomial regression models were fitted to assess the association of ever-use of hangover remedies with drinking frequency, binge drinking frequency, drinking intensity, and AUD symptom count. All analyses were conducted both unadjusted and adjusted for sociodemographic covariates and depressive symptoms. The AUD symptom count associations were additionally adjusted for drinking frequency, binge drinking frequency, drinking intensity to determine whether relations with this outcome were empirically unique from any associations identified with drinking frequency/intensity patterns. Associations were presented as unstandardized regression coefficients (Bs) for the alcohol use problem score and as incidence rate ratios (IRRs) for secondary count outcomes, each with the corresponding 95% confidence intervals (CIs). In supplemental analyses, binary logistic regression models examined the extent to which alcohol use problems are associated with ever-use of hangover remedies with the same analytical/modeling approach and the same set of covariates. Multiple imputation with chained equations (MICE) technique was employed to account for missing data on covariates (n = 158.12.0%). Analyses were performed in R version 4.2.3 and significance was set to 0.05.

Results

Depicted in Table 1, the analytic sample [n = 1312; mean(SD) age = 21.8(0.4) years] was sociodemographically diverse (61.4% female, 75.0% heterosexual, 47.4% Hispanic/Latino). Overall, 3.2% ever used hangover remedies. Approximately 19% had heard of hangover remedies and 8.6% reported they believed hangover remedies worked.

Shown in Table 2, the primary analysis revealed that ever versus never use of hangover remedies was associated with higher alcohol use problem score (adjusted B = 2.29, 95% CI = 0.82–3.76). In secondary analyses, ever-use of hangover remedies was also associated with higher number of drinks per typical drinking day (adjusted IRR = 1.24, 95% CI = 1.02–1.49) and with higher total number of AUD symptoms (adjusted IRR = 1.86, 95% CI = 1.18–3.02). Hangover remedy use was not associated with number drinking days or binge drinking days. Supplemental analyses revealed that higher alcohol use problem score, number of drinks per typical drinking day, and total number of AUD symptoms were associated with increased odds of ever-use of hangover remedy products (Supplemental Table S2).

Table 2

Association of hangover remedy use with alcohol use disorders identification test outcomes.

	Outcome mean (SD)	Unadjusted B	(95% CI)	Adjusted Ba	(95% CI)
Outcome: Alcohol use problem score
Never used hangover remedy	5.4 (4.7)	Ref		Ref
Ever used hangover remedy	7.7 (4.7)	2.45***	(0.96–3.93)	2.29**	(0.82–3.76)
	Outcome mean (SD)	Unadjusted IRR	(95% CI)	Adjusted IRRa	(95% CI)
Outcome: No. past 30-day drinking daysb
Never used hangover remedy	5.6 (5.3)	Ref		Ref
Ever used hangover remedy	6.4 (4.2)	1.15	(0.91–1.47)	1.19	(0.94–1.51)
Outcome: No. past 30-day binge drinking daysc
Never used hangover remedy	2.1 (3.6)	Ref		Ref
Ever used hangover remedy	2.6 (3.0)	1.24	(0.81–1.98)	1.40	(0.91–2.23)
Outcome: No. drinks per typical drinking day in past 30 days
Never used hangover remedy	3.6 (2.4)	Ref		Ref
Ever used hangover remedy	4.4 (2.7)	1.22*	(1.01–1.47)	1.24*	(1.02–1.49)
Outcome: Past Year AUD symptom countd,e
Never used hangover remedy	0.9 (1.5)	Ref		Ref
Ever used hangover remedy	1.7 (1.8)	1.79*	(1.12–2.95)	1.86**	(1.18–3.02)

Note. Exposure variable was ever-use of hangover remedy pills (e.g. dihydromyricetin). AUD = alcohol use disorder; IRR = unadjusted incidence rate ratio; CI = confidence interval; SD = standard deviation.

^*P < 0.05; ^**P < 0.01.

^aSociodemographic characteristics and depressive symptoms shown in Table 1 were controlled for adjusted estimates.

^bDays drinking |$\ge$|1 full drink of alcohol (e.g. can/bottle of beer, glass/cooler of wine/champagne, or shot of liquor/cocktail/mixed drink).

^cDays drinking |$\ge$|5 (born male) or |$\ge$|4 (born female) drinks of alcohol in a row within a couple of hours.

^dSymptoms included: not able to stop drinking once started, failed to do what was normally expected because of drinking, needed an alcoholic drink in the morning, had a feeling of guilt or remorse after drinking, unable to remember what happened because of drinking, injured as a result of drinking, and people concerned about my drinking or suggested to cut down (range: 0–7).

^eAdditionally adjusted for drinking frequency, binge drinking frequency, and drinking intensity.

Discussion

This cross-sectional analysis of 2021 survey data collected among young adults in Southern California provides new evidence of association between hangover remedy use and alcohol use problems. Secondary analyses found small-to-moderate sized associations of hangover remedy use and with higher numbers of drinks per typical drinking day and AUD symptom count. Given that drinking frequency and intensity variables were adjusted for the AUD symptom count analyses, it can be inferred that the relation of hangover remedy use with AUD symptom count may be empirically unique to its association with drinking intensity. To our best knowledge, this study is the first to examine associations of hangover remedy use with alcohol consumption patterns and AUD symptoms among young.

While the prevalence of ever-use of hangover remedies was low (3.2%) in this study, non-negligible subsets of young adults were aware of these products (18.9%) or believed that they would work for addressing hangover symptoms (8.6%). Such positive beliefs about hangover remedies might have played a role in the greater number of drinks per drinking day among those who have used these products. It can be speculated that young adults could drink more because they are not concerned about the negative consequences of experiencing a hangover the next day because they are confident that remedy products will protect against hangovers. Future mediation studies addressing this hypothesis might be warranted.

Many hangover remedy products sold in the U.S. use marketing claims on their packaging that connote efficacy for addressing hangover symptoms (Verster et al. 2021), which may lead to positive beliefs about hangover-remediation efficacy of these products. Strong scientific evidence supporting the efficacy/safety for hangover remedy products in the U.S. for relieving hangover symptoms is not yet available (Verster et al. 2021). The current study raises concern that the availability of these products on the market and premature claims made by hangover remedy manufacturers may create consumer perceptions that are unfounded and could lead to unintended consequences, such as increased drinking in young people. In addition, it is important to identify hangover symptoms as it may be related to alcohol use patterns and access to alcohol use education and prevention, which is not often recognized by young populations. Hangovers are an undesirable effect of heavy drinking and avoidance of hangovers by young people could be an important motivator to reduce their drinking. In an effort to avoid hangovers, young people could be provided during brief intervention with protective drinking strategies (e.g. alternating alcoholic and non-alcoholic drinks, pacing oneself) that can help them avoid intoxication levels that lead to hangovers and other adverse drinking consequences. Given the unknown efficacy and/or safety of hangover remedy products (Verster et al. 2021), medical evaluation and treatment may be an appropriate approach in young people experiencing hangover symptoms frequently.

There were not significant associations of hangover remedy use with past 30-day alcohol use and binge drinking frequencies. Compared to young adults, hangover remedy use might become increasingly prevalent and related to alcohol use frequency among middle/older adults because ethanol metabolism changes with advancing age (Meier and Seitz 2008). That is, the younger is less sensitive to the toxic actions of ethanol compared to the elderly (Meier and Seitz 2008), which might have contributed to the null associations of hangover remedy use with more frequent (e.g. chronic, daily) alcohol use and binge drinking among young adults. However, this hypothesis is speculative, and null findings should be interpreted with caution.

Limitations of this study include reliance on the self-reported data, lack of biochemical verification of alcohol use by respondents, and potentially reduced generalizability and statistical power due to the small sample size of individuals with ever-use of hangover remedy. Due to the cross-sectional study design, causal interpretations cannot be made. Future longitudinal research is needed to examine the prospective relation of hangover remedy use with subsequent alcohol use problems. Lastly, the main independent variable in this study was ever-use of hangover remedy, which may be sensitive for detecting low-threshold use of these products but does not have specificity to distinguish recent vs. past or infrequent vs. regular use of remedy products, which should be addressed in future work. Further studies should evaluate contexts of hangover remedy use behaviors (e.g. reason for use, use frequency), informing clinical decision-making and regulatory policies.

In conclusion, this cross-sectional study of young adults from Southern California in 2021 revealed that ever-use of hangover remedies was of modest prevalence and associated with higher alcohol use problem score and greater number of drinks per typical drinking day and AUD symptom counts. Also, non-negligible subsets of young adults held awareness and positive beliefs about hangover remedies. Given these findings and the risks of excessive alcohol consumption and AUDs during young adulthood, hangover remedy products may merit further scientific and regulatory attention.

Author contributions

Dae-Hee Han (Conceptualization [equal], Formal analysis [lead], Writing - original draft [lead]), Jordan P Davis (Writing - review & editing [equal]), Daryl L. Davies (Writing - review & editing [equal]), John D. Clapp (Writing - review & editing [equal]), Eric R. Pedersen (Writing - review & editing [equal]), Adam M. Leventhal (Conceptualization [equal], Funding acquisition [lead], Validation [lead], Writing - review & editing [equal]). All authors contributed to and have approved the final manuscript.

Conflict of interest: None declared.

Funding

Research reported in this publication was supported by the National Cancer Institute and the FDA Center for Tobacco Products (CTP) under Award Number U54CA180905, National Cancer Institute under award number R01CA229617, and National Institute on Drug Abuse under award number K24DA048160. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the FDA.

Data availability

Data and study materials are available from the authors upon reasonable request.