Sun, sea, shakes

Sunny Beach on the Black Sea is the largest beach resort in Bulgaria. Marketed as “the sunniest resort for the sunniest people”, it attracts many thousands of tourists each year who flock there to relax and enjoy the sandy beach and nightlife. Particularly, the nightlife. With its numerous pubs, bars, clubs, cafes and discos, Sunny Beach visitors regularly drink to excess in pursuit of party fun. There is, of course, a downside to this kind of behaviour. By the next morning the highs of the alcohol-fuelled bender give way to the lows of the alcohol hangover. I could try and put into words what a hangover feels like but I don’t need to because the author Kingsley Amis has already done so to great effect in his 1953 novel “Lucky Jim”. The novel’s main character awakens to find: “A dusty thudding in his head made the scene before him beat like a pulse. His mouth had been used as a latrine by some small creature of the night and then as its mausoleum… He resolved, having done it once, never to move his eyeballs again.”

The symptoms of alcohol hangover will be familiar to many readers of the cool psychology blog. Raging thirst, headache, feeling ill and being unable to stomach food are its hallmarks. Still, a scientific understanding of the alcohol hangover is in its infancy compared with alcohol research more generally. We know lots about alcohol intoxication effects that occur while alcohol is being carried around the body in the blood, and we also know a good deal about the more long-term effects associated with alcoholism. Alcohol hangover, on the other hand, has been very much neglected as a topic of serious scientific study, which is odd given that hangovers make up one of the key constituents of any drinking binge.

This is now beginning to change and there are two broad approaches used to research the alcohol hangover. In laboratory studies a controlled quantity of alcohol is consumed and effects several hours later are monitored. Unfortunately, in order to protect the health of the volunteers taking part, the amount of alcohol allowed in laboratory studies is strictly limited to no more than the equivalent of 6-7 bottles of beer. Because of this, the more “full blown” hangover effects arising from extensive alcohol consumption cannot properly be studied under laboratory conditions. An alternative approach is known as the “naturalistic” study. This entails interviewing drinkers the morning after they themselves have chosen to go on a boozing session often electing to consume much higher quantities of alcohol than would be allowed in the lab. Morten Hesse and Sebastien Tutenges of the Centre for Alcohol and Drug Research at the University of Aarhus in Copenhagen realised that Sunny Beach, being a place where numerous holiday makers consume astonishing amounts of alcohol, is the perfect venue to carry out a naturalistic study of alcohol hangover.

In the name of science four lucky researchers were dispatched to the resort one summer. Each morning they visited hotel swimming pools and beaches to meet Danish tourists aged 16-25. Over the course of one week they asked 76 male and 36 female holidaymakers to describe their nights out, alcohol consumption and alcohol hangover symptoms. Mornings were chosen because this is when hangover effects would be at their most severe. Each person was spoken to three times - after their first night out at Sunny Beach, after their third evening sampling the resort nightlife, and on the final day of their vacation. In most cases this was after their fifth sojourn to the pubs and clubs of the Black Sea holiday destination.

There was a good reason for repeatedly questioning the same individuals. The researchers wanted to try something unique in the field of alcohol hangover research – to be able to chart how hangovers progress over time in the face of continued drinking. It is possible that a tolerance would develop, such that hangovers would become less severe with each passing day. We are all familiar with the idea of tolerance to alcohol – but how would this play out with respect to alcohol hangover? On the other hand, rather than tolerance, perhaps hangovers would become progressively worse over the week-long holiday. This would be related to the idea that hangover is an “opponent process” to excessive alcohol consumption. Opponent processes encourage our bodies to take action against harmful exposures to things like drugs and toxins (such as excessive alcohol) with the aim of reducing those exposures. If hangover represents an opponent process to alcohol, then hangover severity should worsen upon repeated consumption of alcohol, as our bodies seek to reduce the amount of alcohol consumed.

A simple questionnaire called the Acute Hangover Scale was used to measure hangover. This asks you to rate hangover symptoms on a scale of 0 (none) to 8 (incapacitating). The symptoms they were asked to rate were: hangover, thirsty, tired, headache, dizziness, nausea, stomach-ache, heart racing and loss of appetite. Each Danish vacationer was asked to rate “how you feel right now”. The answer in most cases would have been something akin to “awful” because they were mostly suffering from a hangover at the time of asking. So in this environment of sun, sea, sand and alcohol-fuelled partying, how did hangover severity change during the week?

First, I should say that alcohol consumption decreased from the first to the final night out, although it remained overall quite high, at 17 standard units of alcohol on average each night. This is like drinking 10 bottles of Budweiser beer. Still, despite alcohol consumption reducing over the holiday, for most people, hangover severity increased over the week. In other words, the average hangover rating rose at each interview. This is the opposite of what we would have expected to see if there was such a thing as hangover tolerance, which is the idea that we can “get used” to hangovers so that we gradually feel them less strongly. Hangovers getting worse over the duration of the holiday favours instead the “opponent process” idea of hangover being the body’s response of preserving itself from harm by reducing the appetite for further intake of toxins like alcohol. An intriguing finding.

They also questioned whether women experience more severe hangovers than men, and whether age has any impact on alcohol hangover. They found that women’s hangovers were less severe than men’s, or at least so it seemed at first when responses on the hangover symptom scale were compared across men and women. However, closer scrutiny revealed that there was an obvious underlying reason why women’s hangovers were less severe than men’s - because the women tended to drink less than the men. There turned out to be no difference between men’s and women’s level of hangover symptoms when the amount of alcohol consumed was taken into account.

Interestingly hangover symptoms were less severe in the older people that were questioned (but remember that these “older” people were still in just in their 20s). The paper offers no proper explanation for why this might be and it wasn’t simply the case that the older individuals drank less – they didn’t . I have two suggestions. Perhaps as we get older, those people who most suffer from hangovers decide that drinking alcohol isn’t really for them and so they choose not to go on boozy beach holidays. If so, then the older people questioned in the study might seem to be more “hangover tolerant” than the younger ones solely because a proportion of non-tolerant older people would have been holidaying somewhere other than Sunny Beach. The older people at Sunny Beach would be what psychologists would call a “biased sample”. Allied to this, it is also possible that as they get older people learn strategies to avoid hangovers while continuing to drink excessively. There are many remedies for hangovers in circulation, but only a few have been researched properly. Perhaps hangover remedies could be a topic for a future cool psychology blog.

One fascinating conclusion from this study was whether some people are immune to hangover. To answer this, the investigators first had to come up with a definition of hangover based on responses on the Acute Hangover Scale. (If you think about it, just taking any score above zero as indicating a hangover would be inappropriate because we might all tick one or two boxes on the hangover scale on any given day just because of minor ailments like headache – but this doesn’t mean we have a hangover.) First they thought about how much alcohol would need to be consumed so that most people would have a hangover the next day. They decided on 12 or more units (equivalent to around 7 bottles of Budweiser beer). 79 of the study participants had consumed this amount or more on at least one night of the holiday and they were classed as heavy drinkers. The remaining 33 participants were classed as moderate drinkers who mostly reported just a few symptoms, if any. They defined hangover as an Acute Hangover Scale score high enough so that only a small number (10%) of moderate drinkers experienced it. Using this definition they found that only around two-thirds (68%) of the heavy drinkers actually experienced a hangover. This suggests that around one-third of people are immune from hangovers.

The Sunny Beach hangover study is a worthy addition to the cool psychology blog. For a start, how cool is it for researchers to fly to a beach holiday resort in order to collect their data? Why didn’t I think of that? Also, like other studies in the cool psychology blog, it used a very simple and direct approach – they wanted to study hangover so they went to a place where there are lots of hungover people. The findings too are very easy to understand and apply to everyday life. Women don’t necessarily have less severe hangovers than men – they just drink less. Hangovers don’t ease over time – if anything they get worse. And some people, around a third of heavy drinkers, are more or less immune from getting hangovers at all. Are they lucky? In some ways yes, since they can drink to excess and get off lightly the next day. However, without the “opponent process” or natural curb to excessive drinking that hangover provides, perhaps such individuals are more at risk from developing harmful patterns of alcohol consumption storing up possible health problems as they get older. Now there’s a sobering thought.

The reference and a link to the full paper describing this study is included below. This paper was published in the journal Addiction. At the time of writing I was able to download this article for free from the journal’s website.

Hesse, M & Tutenges, S (2010). Predictors of hangover during a week of heavy drinking on holiday. Addiction, 105(3), 476–483. DOI: 10.1111/j.1360-0443.2009.02816.x. Link