A Review of the Literature on the Cognitive Effects of Alcohol Hangover

Richard Stephens; Jonathan Ling; Thomas M. Heffernan; Nick Heather; Kate Jones


Alcohol Alcohol. 2008;43(2):163-170. 

In This Article

Abstract and Introduction

Aims: Alcohol misuse is a prime social and health problem in the UK. This paper presents a critical review of literature on the performance effects in the morning after binge drinking - during the alcohol hangover. Several pathophysiological changes that both follow and outlast acute intoxication may give rise to alcohol hangover effects. We have identified 27 English language peer-reviewed studies that investigate aspects of psychological performance during alcohol hangover following controlled alcohol ingestion. However, the majority of studies had basic methodological shortcomings. Of eight laboratory studies rigorous enough to warrant serious attention, only two showed effects. We interpret these largely negative findings as evidence of an insensitivity that is intrinsic to laboratory-based studies of performance under the influence of alcohol. Several studies have investigated the cognitive consequences of hangover subsequent to naturalistic consumption, where participants have chosen what and where to drink. Although these studies have tended to show effects, participants were always informed at the outset that hangover effects were to be assessed, and participants knew which was the hangover condition. Under these circumstances expectancy effects have possibly contaminated the results significantly. Therefore, naturalistic alcohol consumption studies (and laboratory studies that did not employ a placebo) can be considered as being suggestive of hangover effects, but should not be interpreted as providing definitive evidence of such effects. In conclusion, although there is empirical evidence showing impaired performance as a result of the alcohol hangover, future studies should confirm these findings and overcome the shortcomings of previous research.

Alcohol misuse appears to be rising to the extent that the UK Government considers tackling problem drinking as a social and health priority (Prime Minister's Strategy Unit, 2004). The alcohol-related death rate in the UK has increased from 6.9 per 100,000 population in 1991 to 12.9 in 2005 (Office for National Statistics, 2006). While the dangers of binge drinking have been highlighted (e.g. Pincock, 2003), 35% of all men (42% of those aged 16-24 years) and 20% of all women (36% of those aged 16-24 years) still reported exceeding daily benchmarks on at least 1 day in the previous week to the 2005 Great Britain General Household Survey (Goddard, 2006). A recent government report estimated the societal costs of heavy drinking, including costs to the NHS in treating alcohol-related injuries and illnesses (estimated at £1.7 billion per year), costs associated with alcohol-related crime and disorder (estimated at £7.3 billion per year), and costs due to lost productivity through illness and absence from work (estimated at up to £6.4 billion per year; Prime Minister's Strategy Unit, 2004). The latter estimate includes the costs to the economy of alcohol related deaths. A further, less visible societal cost arises because of alcohol-related impairment in the morning after an evening's binge drinking-due to the so-called alcohol hangover.

Estimating the societal costs of hangover is prone to inaccuracy when one considers that hangover effects may include lateness, accident risk, poorly performed work and disputes (Crofton, 1987) in addition to absenteeism. Even the recent report by Pittler et al. (2005) cites hangover cost estimates (£2 billion) that were made 20 years ago and without reference to the original author's caveat concerning the crude nature of the costings (Crofton, 1987). A recent report by the Prime Minister's Strategy Unit (2004) estimates that the cost to the UK economy of alcohol-related absenteeism from work (due in part to hangover) is between £1.2 and £1.8 billion per year. However, this estimate does not take into account effects of depleted worker performance and includes lost days due to long-term health problems associated with alcohol dependency. In the grey literature, the BBC (BBC, 2004) cites research carried out by an employment agency estimating that hangovers cost the UK economy £2.8 billion a year due to the average of 2.3 sick days per person per year, augmented by a further 2.5 days per year that workers spend, on average, hungover on the job. Wiese et al. (2000) cited an estimate of hangover costs to the US economy of $148 billion a year, but this estimate was criticized by Becker (2001). A fair conclusion would be that hangover costs are indeterminate but significant.

Several reviews of the hangover state have been undertaken. Finnigan and Hammersley (1992) report findings from a small number of hangover and performance studies, although this review has now become dated. In a brief review of hangover appearing as an editorial piece, Calder (1997) recounted the findings of several performance studies but did not conduct any critical evaluation. Swift and Davidson (1998) gave a detailed account of the mechanisms and mediators of hangover but did not discuss performance effects. Wiese et al. (2000) conducted a detailed systematic review of the causes, pathophysiological characteristics and treatment of alcohol-induced hangover. They defined hangover as 'the presence of at least two symptoms (out of: headache, poor sense of overall well-being, diarrhoea, anorexia, tremulousness, fatigue, and nausea) occurring after the consumption and full metabolism of alcohol with sufficient severity to disrupt the performance of daily tasks and responsibilities' (p. 898). However, the notion that hangover disrupts performance of certain tasks is not as safe an assumption to make as it might at first appear. Certainly, Wiese et al. (2000) do not make a convincing case. They reviewed several studies claiming to show performance effects of hangover, but they recounted findings without any critical evaluation, and they omitted a large number of published peer-reviewed hangover performance studies.

The present review offers a more critical analysis of all published peer-reviewed papers on hangover performance that we could find. For the purposes of this review, performance effects are defined primarily as changes in cognitive functioning assessed using cognitive tests. However, more everyday aspects of performance, such as driving or performance in a management-style decision-making game are also considered. We began by searching the PSYCInfo database but this missed a large number of relevant studies and produced many false positives (e.g. non-performance based studies). Therefore, while some papers were identified from database searches, the majority were identified from references cited in papers already obtained. Some further papers were identified using citation searching of obtained papers (i.e. searching forwards for papers that cite the papers we had obtained). This was done using the MIMAS Web of Knowledge database.

We briefly outline the biological mechanisms that may underlie hangover effects before embarking on a detailed review of the literature on the performance effects of alcohol hangover. We set out to include all the peer-reviewed studies published to date but it is possible that one or two of the less well-cited studies will have been omitted.


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