Alcohol and the coronavirus pandemic: ALCOHOL AND SOCIETY 2021 - individual, societal and policy perspectives
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SP
EC
IAL
ED
Alcohol and the
ITI
ON
coronavirus pandemic:
individual, societal and policy perspectives
O L A ND
ALCOH
T Y 2 0 21
SOCIE
A REVIEW OF INTERNATIONAL AND SWEDISH RESEARCH
Organisations initiating this report are voluntary or regarding sober life styles, public opinion in this regard,
academic organisations independent of commercial as well as care of children. The foundation have eight
interests. member organisations in three Nordic countries. CERA is
an interdisciplinary and collaborative centre for education
SFAM is the professional and scientific college of and research into hazardous use, abuse and addiction at
general practitioners (family physicians) in Sweden with Gothenburg University – which works to strengthen and
continuing professional development, training of future develop research and education in the field of addiction,
GPs, assessment of competence, quality improvement and to disseminate scientific expertise to people working
and research in general practice/family medicine as main professionally in the field of abuse and addiction, and other
areas of interest. The Swedish Society of Nursing is a interested parties. The Swedish Society of Addiction
nonprofit organization and a forum for discussing and Medicine works to promote research and education in the
developing nursing care by promoting nursing research, addiction medicine field, and professional development in
ethics, education and quality in nursing. IOGT-NTO focuses all specialist care professions. SIGHT is Sweden’s research
on the effects of alcohol and narcotics on individuals arena for global health equity with a focus on children
and society, but is also engaged in broad social and club and youth: a multidisciplinary tool-box to fulfill the 2030
activities. The foundation Stiftelsen Ansvar För Framtiden Agenda.
aim to further Nordic cooperation and scientific research
Views expressed in this report are those of the authors and A Swedish language version of this report is also available
do not necessarily reflect those of the organisations that from www.iogt.se, www.swenurse.se or cera.gu.se.
initiate the work.
Graphic design and cover illustration:
Suggested citation: ”Andreasson S, Chikritzhs T, Dangardt Petra Handin, Poppi Design
F, Holder H, Naimi T, Sherk A, Stockwell T. (2021). Alcohol
and Society 2021: Alcohol and the coronavirus pandemic: Printers: Fridholm & Partners AB, Göteborg
individual, societal and policy perspectives. Stockholm:
Swedish Society of Nursing, SFAM, SAFF, CERA, The ISBN: 978-91-982220-6-7 (print version in Swedish)
Swedish Society of Addiction Medicine, SIGHT, Movendi
ISBN: 978-91-982220-7-4 (pdf in Swedish)
International & IOGT-NTO.”
ISBN: 978-91-982220-8-1 (pdf in English)
© Published by Svensk Förening för Allmänmedicin,
Svensk sjuksköterskeförening, CERA, Stiftelsen Ansvar
URN: urn:nbn:se:iogt-2021-aos-en
för Framtiden, Actis-Rusfeltets samarbeidsorgan, Alkohol
& Samfund, Hela Människan, IOGT-NTO, MA – Rusfri Published with support from Stiftelsen Ansvar
Trafikk, MHF Motorförarnas Helnykterhetsförbund, för Framtiden (SAFF).
Sveriges Blåbandsförbund och Sveriges Frikyrkosamråd,
Svensk förening för Beroendemedicin, SIGHT, Movendi
International 2021.
CENTRUM FÖR UTBILDNING OCH
FORSKNING KRING RISKBRUK,
MISSBRUK OCH BEROENDE (CERA)
Sveriges
Frikyrkosamråd
FOREWORD
Foreword
2020 was the year when the world standing of a relatively established topic, the
came together to address a shared researchers took a broad scan of different
global challenge. COVID-19 compelled information sources in order to highlight and
governments, authorities, and researchers contextualize areas where concerns may only
from all over the world to work together just now be emerging.
to save human lives. The aim of the “Alcohol and Society”
series of reports is to highlight what scientific
Different countries’ corona strategies have studies can tell us about the effects of alcohol
handled alcohol consumption in very different consumption at both an individual and a
ways. Some countries were quick to reduce societal level. This is the eighth such report.
the availability of alcoholic drinks, while others Previous years’ reports have focused on such
have viewed alcohol as a possible lifesaver issues such as alcohol and young adults,
for the local economy. The role of alcohol second-hand effects of alcohol consumption,
consumption, and its consequences, have not alcohol and violence, and alcohol and
been addressed as part of Sweden’s corona pregnancy. These reports, along with this
strategy. year’s edition, are available on our respective
The researchers behind the series of websites. The following organisations support
reports entitled “Alcohol and Society” conse- this year’s report:
quently decided that they would like to take a • The Center for Education and Research
closer look at the role of alcohol consumption on Risk, Abuse and Addiction (CERA),
in spreading the corona virus and contracting University of Gothenburg
COVID-19. The theme of the 2021 report is,
• The Swedish Society of Nursing Kristina Berglund
therefore, the effect of alcohol on the immune Director, CERA,
system and on transmission of the virus, given • Stiftelsen Ansvar för Framtiden (SAFF)
University of Gothenburg
the effect of alcohol on human behaviour. The • The Swedish Association of General
Ami Hommel
report also examines the ways in which the Practice
Chair, The Swedish Society
effects of the pandemic – in terms of anxiety, • The Swedish Society of Addiction of Nursing
social isolation, unemployment, etc., – have Medicine
Magnus Isacson
affected alcohol consumption and the ways
• Swedish Institute for Global Health Chair, The Swedish Associa-
in which the alcohol industry and the world’s tion of General Practice
Transformation (SIGHT) at The Royal
governments have responded to these
Swedish Academy of Sciences Arne Winerdal
challenges. Chair, SAFF
As in previous years, the report has been • IOGT-NTO
written by a group of some of the world’s • Movendi International Joar Guterstam
Chair, The Swedish Society
leading alcohol researchers, led by Harold of Addiction Medicine
Holder. It is our hope that this report will help
As the pandemic is still ongoing and the increase knowledge and awareness of Peter Friberg
alcohol-related risks in connection with both Director, SIGHT
situation is changing rapidly, the research
group has been obliged to adjust its choice of this and future pandemics, both in purely Johnny Mostacero
method and sources accordingly. The report physical terms – in that alcohol weakens the Chair, IOGT-NTO
is therefore different in focus from previous immune system – as well as increased risk of
Kristina Sperkova
ones. Rather than focusing on critiquing the spread of infection, due to alcohol’s effect Chair, Movendi
scientific evidence to improve our under- on human behaviour. International
ALCOHOL AND THE CORONAVIRUS PANDEMIC: INDIVIDUAL, SOCIETAL AND POLICY PERSPECTIVES 3
EXECUTIVE SUMMARY
Executive summary
• Alcohol use may increase the risk of consumption have mostly decreased in low
COVID-19 infection and of its severe com- income countries. Local factors and govern-
plications while also causing other medical ment policies on alcohol availability are key.
and social problems that burden healthcare In Sweden, consumption was reduced by
and other services. 7% during March and April2020 because
increased retail sales were more than offset
• Alcohol increases COVID-19 transmission by reduced travelers’ imports.
by reducing social inhibitions even at low
consumption levels, and causing severe • Domestic violence has increased in many
impairment at higher levels, thus disrupting places during the pandemic, a problem in
preventative strategies, such as social which alcohol use is often implicated.
distancing and hand hygiene.
• Traffic crashes decreased in most countries
• Many complications from heavy alcohol use due to reduced travel.
are themselves risk factors for more serious
outcomes from COVID-19 infection (e.g. • COVID-19-related isolation, boredom,
diabetes, obesity, cardiovascular disease). stress and depression during the pandemic
can be worsened by alcohol consumption;
• Alcohol use, especially heavy use, can these same factors may also lead to
compromise immune system responses excessive alcohol consumption.
and also increase susceptibility to serious
respiratory illnesses. • Many governments have exempted
off-trade alcohol outlets and alcohol
• Alcohol-related problems consume manufacturers from lockdown conditions,
substantial health care resources; during designating these as essential services,
COVID-19 strong alcohol control policies decisions that, in many countries, have
could relieve these overstretched services been influenced by alcohol industry
by reducing both alcohol- and COVID- lobbying.
related healthcare demand.
• Major regulatory changes or concessions
• In high income countries, surveys tend (e.g., liberalizing home delivery of alcohol)
to show that more people increased will be difficult to reverse and are therefore
than reduced drinking during the early likely to persist after the pandemic.
COVID-19 lockdowns, while total sales and
4 ALCOHOL AND THE CORONAVIRUS PANDEMIC: INDIVIDUAL, SOCIETAL AND POLICY PERSPECTIVES
EXECUTIVE SUMMARY
• The following public health policies are • Given the strong inter-relationship
recommended for pandemics: between alcohol and COVID-19, alcohol
policies should be maintained or strength-
- suspend alcohol service at sports arenas ened during the pandemic, not relaxed.
and large events;
• Effective policies, including those to
- prohibit alcohol consumption in public reduce physical availability of alcohol
places such as parks and beaches; and increase its price through increased
- restrict drinking at high-risk on-trade
alcohol taxes and minimum prices, could Alcohol increases
help limit viral spread, reduce burden on
settings such as bars and nightclubs;
health services and raise much needed
COVID-19
- impose limits on home delivery, if extra government revenue. transmission
permitted at all; by reducing
social inhibitions
- make clinical and treatment provisions
for people experiencing all types of even at low
alcohol-related problems, including consumption
dependence; levels, and
- increase access to mental health services, causing severe
including online services. impairment at
• Health authorities should advise individ-
higher levels.
uals at high-risk for infection or serious
complications to reduce or avoid alcohol
use (e.g., elderly, overweight, diabetic,
smokers, people with respiratory disease,
cancer, or cardiovascular disease).
ALCOHOL AND THE CORONAVIRUS PANDEMIC: INDIVIDUAL, SOCIETAL AND POLICY PERSPECTIVES 5
PHOTO: FUSION MEDICAL ANIMATION / UNSPLASH
Authors
Sven Andreasson Tanya Chikritzhs Frida Dangardt Harold Holder
Karolinska Curtin University, Sahlgrenska Academy Senior Scientist
Institutet, Depart- National Drug and University Emeritus and former
ment of Public Research Hospital, The Queen Director of Prevention
Health Sciences, Institute, Perth, Silvia Children’s Research Center,
Stockholm, Australia Hospital – Paediatric Pacific Institute
Sweden Clinical Physiology, for Research and
Gothenburg, Sweden Evaluation, Berkely,
CA, USA
Timothy Naimi Adam Sherk Tim Stockwell
Canadian Institute Canadian Institute Canadian Institute
for Substance for Substance for Substance
Use Research, Use Research, Use Research,
University of University of University of
Victoria, BC, Victoria, BC, Victoria, BC,
Canada Canada Canada
6 ALCOHOL AND THE CORONAVIRUS PANDEMIC: INDIVIDUAL, SOCIETAL AND POLICY PERSPECTIVES
INTRODUCTION
Introduction
The COVID-19 pandemic has had enormous terms of an individual’s susceptibility to
impacts on societies worldwide, and its infection and transmission of the virus
impact on alcohol consumption, related through physiological and cognitive-behav-
harms and alcohol control policies has also ioral pathways. We provide evidence, in
been significant. In turn, alcohol has played a particular, for how alcohol’s various effects
central role in the transmission of COVID-19 on behavior have influenced the course of the
between individuals and across populations, pandemic.
and has negatively influenced medical, social We then examine the converse, that is, the
and economic effects of the pandemic. pandemic’s effect on population-level alcohol
For this report, our aim was to synthesize consumption and related social harms. These
the emerging and rapidly expanding evidence effects are mediated through a variety of
for multiple, complex relationships between forces related to the large-scale disruption
alcohol and COVID-19 that operate across wrought on social and economic life as well
many aspects of life. Due in large part to the as policy responses that specifically affect
uniqueness and uncertainties of the present alcohol availability (e.g. alcohol bans, lifting
state of play, this report has some differences of off-trade restrictions). We then reflect on
to previous reports in this series. Rather than how governments have responded to chal-
focusing on critiquing scientific evidence lenges imposed by the pandemic and how the
(e.g. study methods, design limitations) to actions of alcohol industry vested interests
improve our understanding of a relatively have played a major role in shaping policy
established topic, we took a broad scan of decisions, that if left unchecked, will increase
different information sources in order to alcohol’s burden on public health and safety
highlight and contextualize areas where in the longer-term.
concerns may only just now be emerging that We conclude by summarizing what has
are specific to alcohol use and COVID-19. We been learned about alcohol consumption,
have also drawn upon decades of research related outcomes and activities during the
evidence regarding the role of alcohol policies pandemic, and provide recommendations for
in influencing the consumption of alcohol in individuals and governments, with a particu-
a population and, in turn, the impacts of this lar focus on alcohol policies. Alcohol policies
consumption on health and social outcomes. have a crucial role to play both in reducing
The report begins by discussing the effects alcohol-related harms and controlling
of alcohol consumption on COVID-19 in transmission of the virus.
ALCOHOL AND THE CORONAVIRUS PANDEMIC: INDIVIDUAL, SOCIETAL AND POLICY PERSPECTIVES 7
PHOTO: ANNIE-SPRATT / UNSPLASH 8 ALCOHOL AND THE CORONAVIRUS PANDEMIC: INDIVIDUAL, SOCIETAL AND POLICY PERSPECTIVES
1 EFFECTS
1 Implications of physiological
and cognitive effects of alcohol
for transmission of COVID-19
Alcohol use, particularly heavy use, may not always successful at fully combatting
increase an individual’s risk of contracting new invading pathogens. This is where the
and transmitting infectious disease as well as acquired (or adaptive) immune system comes
increase symptom severity. Elevated risks of in, after being activated by chemical cues that
infection and disease progression have been signal the presence of a pathogen.
established for alcohol for other communica- The human acquired immune system has
ble diseases such as tuberculosis, pneumonia evolved to be highly specialist and tar-
and HIV.1 There are many reasons to suspect get-specific such that it is able to distinguish
that this will also prove to be the case for between subtly different pathogens. Two key
COVID-19. Pathways by which this may occur cell types – T cells and B cells – are involved.
include direct effects on immune system Together these cells directly kill infected cells
and organ-specific functioning (e.g. lungs, by ‘learning’ to produce specific antibodies to
liver, gut), psychiatric conditions, as well neutralise the pathogen. These cells even keep
as through alcohol’s psychoactive effects a ‘memory’ of previously encountered path-
on cognitive functions and behaviors (e.g. ogens, including viruses, for use when future
inhibition, risk taking) that may also interact infections strike. It takes time to activate the
with drinking context to influence risk. acquired immune system, however, and while
innate immunity occurs within a few hours,
1.1 Immune system acquired immunity takes days to launch.2
Immunity to infection in humans occurs Aging has a profound effect on the human
through both innate and acquired mecha- immune system. Generally speaking, innate
nisms. Most humans are born with some immunity is more active at younger ages
innate immunity to infection, such that our and acquired immunity builds up over time.
bodies are able to detect common infectious However, older age is associated with a
agents. Our innate immune system activates general decline in immune function. The
a first line of defence in the form of mac- innate and acquired immune systems tend
rophage, dendritic and natural killer (NK) to respond more slowly and less efficiently to
cells to deal with common threats. But the pathogens as people age. Low-grade chronic
innate immune system is a generalist and inflammation is also more common among
ALCOHOL AND THE CORONAVIRUS PANDEMIC: INDIVIDUAL, SOCIETAL AND POLICY PERSPECTIVES 9
1 EFFECTS
older people and this tends to have a dulling ural killer’ (NK) cells known to play a key
effect on the immune system. These common role in COVID-19 infections, as well as its
consequences of ageing make it more likely role in a process known as ‘hyper-inflam-
that an invading pathogen or virus – such mation’ i.e. an overreaction of the immune
as COVID-19 – will gain the upper hand and system.6,7 An episode of heavy alcohol use
cause serious disease.3,4 will initially increase an inflammatory
There are several reasons to be concerned response and, later, reduce the activity of
that alcohol use might compromise both cells involved in immune responses.8 Thus,
Alcohol use may
innate and acquired immune responses to alcohol use may both reduce immunity
both reduce coronaviruses: to an infection and also increase the risk
immunity to an • Alcohol increases the number of receptors of serious complications by triggering an
infection and in the lungs, digestive system and heart excessive immune response.
also increase the that provide the main entry points for • Alcohol use may also impair a person’s
risk of serious coronavirus-type infections such as ability to develop immunity to infection.
SARS.5, 210, 211 This likely results in an Alcohol has been shown, for example, to
complications
increased susceptibility to coronavirus interfere with the production of T- and
by triggering an infections generally, including COVID-19. B-cells and reduce blood concentrations
excessive immune • Alcohol use may increase susceptibility of key antibodies involved in acquired
response. to COVID-19 infection and complications immune system responses.6,7,9–11
through its effects on monocytes and ‘nat-
FIG 1 Possible pathways for alcohol’s role in activation and inflammation in COVID-19 disease, modified from Golchin et al.12
Alcohol effects
+
–
SARS-CoV-2 virus
particles
Y
Y + –
Alcohol increases the number
of ACE2 receptors to which
the SARS-CoV-2 (”covid”) virus
particles can bind to infect the
Cytokines host cells;
Cellular (e.g., lung Dendritic cell may activate the increased
aveolar) lining Natural killer cell production of cytokines, which
Antibodies can contribute to a dangerous
{
Macrophage B cell excessive inflammatory
reponse characteristic of covid
infection (”cytokine storm”);
Y
T
Antigen-presenting cell interferes with the functioning
T cell
Helper T cell of T cells;
Killer T cell weakens the virus-neutralizing
antibody response.
Innate immune system Adaptive immune system
10 ALCOHOL AND THE CORONAVIRUS PANDEMIC: INDIVIDUAL, SOCIETAL AND POLICY PERSPECTIVES1 EFFECTS
1.2 Specific organs and body systems
PHOTO: MUFID MAJNUN / UNSPLASH
Alcohol use is well established as a signifi-
cant risk factor for many health conditions
associated with worse outcomes and compli-
cations from COVID-19. Alcohol adversely
affects multiple organs and body systems,
including the liver, heart and lungs, and the
more alcohol consumed the worse the effects.
It follows that the combined effects of alcohol
use, particularly heavy use, and COVID-19 on
these systems will increase susceptibility to
serious complications and likelihood of death.
Lungs
Heavy alcohol consumption increases the
risk for lung infections, both viral and bacte-
rial.212, 213 It may also increase the severity of
Acute Respiratory Distress Syndrome (ARDS)
and risk of permanent lung damage5 through
many mechanisms and pathways. For
example, chronic heavy alcohol consumption
both increases ACE2-receptor expression in
the respiratory system (a main pathway for and altered mucosal immunity, which can
coronavirus-type entry and infection) and result in systemic inflammation and liver
inflammatory responses. As discussed above, damage.14–16
heavy alcohol use also compromises both Both heavy alcohol use, especially chronic
innate and acquired immunity to infection. continuous use, and COVID-19 infection are
In combination, these factors may lead to known to occasionally result in some form
increased susceptibility to infection, severity of serious liver damage. It follows that the
of infection and subsequent lung damage combined effects of alcohol use and COVID-
which may be long-lasting.5 In support 19 infection could create a very serious risk
of this, a recent study of permanent lung for liver dysfunction. A noticeable incidence
damage following COVID-19 infection found of liver damage accompanied by abnormal
that presence of alcohol use disorder was a ranges of liver derived enzymes and pro-
significant risk factor for pulmonary fibrosis, teins has been reported during COVID-19
in addition to older age, co-morbidity and disease.17,18 Different mechanisms have been
smoking.13 suggested for liver injury during COVID-19
infection including immune-mediated
Liver and digestive system hepatitis, direct effects of the virus, drug-in-
When alcohol enters the body, its first duced liver injury from medications used to
interaction is with the alimentary canal. The treat COVID-19, infection-induced systemic
process of alcohol metabolism (oxidative and inflammation, hepatic congestion secondary
non-oxidative) induces gut inflammation to mechanical ventilation and pre-existing
which impairs mucosal immunity and affects liver disease.17
the mucus barrier as well as the epithelium, Patients with liver cirrhosis are also at
which permits virus and other microbes to increased risk of infections and associated
reach the liver through the portal vein. This complications due to cirrhosis-associated
initiates bacterial overgrowth, dysbiosis immune dysfunction, which may add to the
ALCOHOL AND THE CORONAVIRUS PANDEMIC: INDIVIDUAL, SOCIETAL AND POLICY PERSPECTIVES 111 EFFECTS
increased mortality from COVID-19 seen 1.3 P
sychiatric conditions and
in people with cirrhosis compared to those mental health
without cirrhosis.19 A study from India found
Serious complications from COVID-19 infec-
a greater chance of serious complications and
tion, as opposed to the other major recent
mortality among COVID-19 patients with
coronavirus pandemics, SARS and MERS,
predominantly alcohol induced liver cirrhosis
is primarily (but not exclusively) a problem
and liver failure.20
for older people, and the majority of hospital
However, there is mixed evidence from two
admitted patients are above 70 years of
studies of non-alcohol induced liver disease
age.26–28 People with dementia are at greater
in terms of increased risk of complications
risk of developing neuropsychiatric symp-
after contracting COVID-19. A relatively small
toms when infected by COVID-19.29 In this
study from China did not find significant
context it is important to recall that alcohol is
increased risk of complications21, while
recognized as a powerful neurotoxin, known
another larger study from the US found that
to cause or contribute to a wide range of
patients with a history of non-alcohol-related
neurological disorders including dementia,
liver disease were significantly more likely to
with risks increasing with age.30 Recent
be hospitalised.22
research also suggests that regular alcohol
Heart and cardiovascular system use, even at low levels, diminishes brain
volume and increases brain ageing.31
There are many pathways for cardiovascular
The scientific literature on direct psy-
damage by COVID-19 to occur including:
chiatric effects of COVID-19, as opposed
increased clot formation, vasculitis, vascular
to general psychological distress caused by
fibrosis, myocarditis and pericarditis.23 These
the pandemic and its restrictions, remains
may result in heart failure, arrhythmias,
limited. Previous studies on MERS and
cardiogenic shock, as well as inflammatory
SARS, however, have demonstrated a
and coronary illnesses. There is a notable
range of neuropsychiatric disorders such as
correlation between cardiovascular disease
encephalopathy, mood changes, psychosis,
and COVID-19 severity with hypertension
neuromuscular dysfunction, or demyelinating
and diabetes, but no studies have looked
processes.32
at the effect of alcohol consumption in this
A recent systematic review and meta-analy-
context.24
sis published in July 2020, where the indirect
Brain effects of coronavirus infections on the
mental health of people who are not infected
Heavy alcohol consumption is known to
were excluded, focused on psychiatric signs
change immune response in the brain’s
or symptoms and symptom severity, with
frontal cortex and increase pro-inflammatory
diagnoses based on established diagnostic
signaling. Heavy alcohol use can also affect
manuals. Common symptoms among hospital
the permeability of the blood-brain barrier.
admitted patients for SARS or MERS were
It is plausible that abnormal alcohol-induced
confusion, depression, anxiety, impaired
inflammatory cytokine release (innate
memory and insomnia. In the post-illness
immune response) could increase the like-
stage, 32.2% suffered from post-traumatic
lihood of excessive inflammatory responses
stress disorder.33
observed in patients with severe COVID-19.
When data for COVID-19 were analyzed,
If this is the case, disease severity may be
a high proportion of patients treated in
enhanced. Disruption of the blood-brain
intensive care were found to be confused
barrier associated with chronic alcohol use
(65%) and agitated (69%).33 One study found
may also increase the possibility that invading
that 33% had a “dysexecutive syndrome”,
pathogens, including COVID-19, infiltrate the
which encompasses cognitive, emotional,
brain.25
12 ALCOHOL AND THE CORONAVIRUS PANDEMIC: INDIVIDUAL, SOCIETAL AND POLICY PERSPECTIVES1 EFFECTS
and behavioral symptoms, at discharge.34 It by the pandemic, is yet to emerge. It is
should be noted, however, that a prolonged reasonable to anticipate, nonetheless, that
ICU stay in itself is a risk factor for psychiatric given alcohol’s known short and long-term
disorders, especially delirium.35 Furthermore, cognitive effects, there is significant scope for
COVID-19 survivors return to a society in deleterious impacts, particularly among older
deep crisis, sometimes with enforced social people, those with dementia and possibly also
isolation. Their countries, neighborhoods and people with mood disorders.
families may be unable to meet basic needs,
including food and medical supplies, due to 1.4 Epidemiological studies and
supply chain problems or loss of livelihood. methodological challenges
Other countries may be enforcing strict A key concern regarding our current under-
lockdowns and physical isolation – condi- standing of alcohol’s role in COVID-19 infec-
tions that may further increase the risk for tion, transmission and disease progression,
psychiatric complications. A British survey of is that most large studies have not addressed
non-infected people, for instance, found that alcohol use and drinking patters (e.g. levels
almost one in five adults (19.2%) were likely and frequency of drinking) or the presence of
to be experiencing some form of depression alcohol use disorders at the time of infection,
during the pandemic in June 2020; this had as risk factors. Unfortunately, this leaves some
almost doubled from around 1 in 10 (9.7%) aspects of the relationship between alcohol
before the pandemic (July 2019 to March and COVID-19 so far relatively unexplored.
2020).36 We discuss here on some early, suggestive
Another study of psychiatric presentations findings.
to 20 emergency departments (ED) across A review of 34 studies found that in patients A review of 34 studies
the U.S. Midwest during lockdown reported found that in patients
with severe or fatal COVID-19, the most
a large drop (61%) in the proportion of with severe or fatal
prevalent chronic comorbidities were obesity
all behavioral health complaints coded as COVID-19, the most
and hypertension followed by type 2 diabetes,
prevalent chronic
suicidal ideation. Conversely, the proportion cardiovascular disease, respiratory disease, comorbidities were
of all behavioral complaints coded for alcohol cerebrovascular disease, malignancy, kidney obesity and hypertension
increased somewhat (28.2% to 33.5%). The disease and liver disease, but alcohol use was followed by type 2
authors noted that it was very difficult to not investigated.38 diabetes, cardiovascular
determine the extent to which apparent For future studies, a complicating factor disease, respiratory
declines in ED presentation for suicidal idea- in determining whether there is a causal disease, cerebrovascular
tion reflected real declines in the population pathophysiological pathway between alcohol disease, malignancy,
or was a result of fewer people seeking – but and the effect of COVID-19 infection may be kidney disease and liver
still requiring – emergency mental health disease.
the frequent co-occurrence of other major
assistance due to the stay-at-home order. This risk factors that have both independent and
will become clearer when presentation rates inter-related effects. Obesity for instance, is
can be compared against general population not only a significant risk factor for a severe
suicide rates. Alternatively, it is plausible course of COVID-19, but also for hypertension
that social distancing might have reduced and type 2 diabetes; heavy drinking is a risk
stressors related to suicidal thoughts or led factor for all three of these conditions. Each of
large numbers of sufferers to use on-line or these conditions are also considered indi-
tele-help services.37 vidual risk factors (i.e. without the necessary
The full extent to which alcohol use has presence of other risk factors) for a severe
affected individuals with pre-existing or course of COVID-19. The mechanisms for an
newly acquired mental health conditions, association between obesity and COVID-19
either as a direct result of infection or a result remains unresolved, but a possible explana-
of social and economic changes wrought tion is that the virus not only accumulates in
ALCOHOL AND THE CORONAVIRUS PANDEMIC: INDIVIDUAL, SOCIETAL AND POLICY PERSPECTIVES 13PHOTO: KELLY SIKKEMA / UNSPLASH
adipose tissue, but that adipose tissue is also 42%, although whether this was due to those
an origin for the inflammatory response.19 in the ‘ever’ group having a higher frequency
In a cohort study of nearly 400,000 of exposure to high-risk settings (e.g. pubs,
participants, including 760 hospitalisations nightclubs, restaurants), as opposed to
for COVID-19, heavy alcohol use (assessed biological factors, was not studied.41
several years before) was not associated with Unexpected reports of apparent protective
an increased risk for COVID-19 infection or effects from regular heavy alcohol consump-
hospitalization.39 Notably, it was common for tion have also emerged. It has been reported
participants to have stopped drinking before that for people with both chronic lung disease
the study due to prescribed medication and and a history of alcohol or substance misuse,
underlying health conditions which could a positive COVID-19 result is less likely.42 This
mask increased risk due to alcohol. finding is contrary to what would be expected
A review of substance use disorders on the basis of many past studies which
and COVID-19 found that people with have demonstrated a relationship between
such disorders are at greater risk of worse chronic lung disease and alcohol including
COVID-19 outcomes. Factors that increased pneumonia, tuberculosis, respiratory syncytial
risk included stress, pre-existing cardio-pul- virus infection, and acute respiratory distress
monary conditions, compromised immunity, syndrome (ARDS).43 It is possible that this
factors related to health care, lack of social apparent protective effect was an artefact
distancing and wide relaxation of restrictions of reduced social circulation and extra
on alcohol sales, particularly on-trade.40 A precautions taken by people with chronic lung
US case-control study found that alcohol disease, since the study only examined the
consumption (ever versus never) increased likelihood of a positive test result rather than
the risk of testing positive for COVID-19 by severity of disease.
14 ALCOHOL AND THE CORONAVIRUS PANDEMIC: INDIVIDUAL, SOCIETAL AND POLICY PERSPECTIVES1 EFFECTS
A UK study also found that red wine of the virus – relies heavily on individuals
consumption was associated with decreased consciously curtailing normal every-day social
likelihood of testing positive for COVID-19.44 interactions that involve physical contact (e.g.
However, like many other observational shaking hands, hugging) or close proximity to
studies involving self-reported alcohol use45, one another (e.g. shared transportation, office
it is likely that apparent protective effects of space, social dining, dancing).
red wine are due to other protective factors Alcohol, one of the world’s most commonly
common among people who regularly consumed psychoactive substances, has long
consume red wine (in this case, 52% of the been known to reduce inhibition even at
adult population) e.g. diet and socioeconomic low levels and impair judgement starting at
status. moderate levels. These cognitive effects are
established risk factors for a range of negative
1.5 C
ognitive-behavioral effects of social harms including impaired driving,
alcohol and drinking context violence, sexual risk taking and injuries.
Alcohol has a profound impact on trans- Alcohol intoxication, in particular, increases
mission of COVID-19. At this point, much sexual risk-taking, aggressive behavior,
of the evidence for increased risk associated and the risk of motor vehicle accidents.46
with alcohol is around behavioral effects on Supported by laboratory studies with humans
drinkers, and the characteristics of drinking and animals, it has been theorized that
settings or contexts (i.e. social factors, alcohol undermines judgement and inhibitory
entertainment activities), rather than direct behaviors by narrowing drinker focus onto Alcohol, one
physiological effects on host susceptibility provocative or instigatory information at the of the world’s
expense of inhibitory cues.47 Several studies of
and transmissibility.
adolescents and youths exposed to different
most commonly
Cognitive-behavioral effects doses of alcohol (blood alcohol contents consumed
Most of the behavioral effects of alcohol that ~0.06–0.09%) for instance, demonstrate psychoactive
impact COVID-19 transmission relate to its impaired inhibitory control on a variety of substances, has
response inhibition tasks.48,49
acute effects that result in reduced inhibition
Alcohol exposure also impairs performance
long been known
and increased relaxation at relatively low
levels of consumption, and moderate to and cognitive processes such as memory, to reduce inhibition
severe impairment of executive function at ability to focus attention, and planning, even even at low
higher levels of use. As a very contagious at low levels. While alcohol intoxication has levels and impair
been shown to impair judgment, laboratory
virus, COVID-19 is easily transmitted
studies of perception, motor skills and cog-
judgement starting
between people by direct physical contact or
through the air, with risk increasing dramat- nitive performance show that decline begins at moderate levels.
ically with closer proximity. This means that with BACs >0.0, that is, even after the first
mindful individual actions are essential to drink.50–52 This suggests that alcohol can lead
reducing personal exposure to the virus from to poor decision making well before intoxica-
others, as well as limiting exposure to others. tion is perceived or the drinker feels ‘drunk’.
Thus, a pandemic creates a situation where This could lead to behaviors considered
individuals need to be aware of increased undesirable under pandemic conditions such
personal risk and take effective preventative as hugging each other or simply standing too
actions, including frequent hand washing, close to others.
sneezing and coughing hygienically, and
maintaining social distancing. Critically, Drinking contexts
social distancing – the most effective strategy Several common drinking contexts interact
currently available for reducing personal with the acute cognitive and behavioral
risk and containing community transmission effects of alcohol on drinkers in manner
ALCOHOL AND THE CORONAVIRUS PANDEMIC: INDIVIDUAL, SOCIETAL AND POLICY PERSPECTIVES 151 EFFECTS
that is likely to exacerbate transmission of These theoretical concerns are reinforced
COVID-19. These include going to bars and by the numerous reports and studies docu-
clubs, attending college or university parties, menting that alcohol-centric social contexts
or attending large private functions. Although have played a crucial role in ‘super-spreader’
these drinking contexts may be considered events, amplification of the outbreak early
associated with alcohol consumption, the in the pandemic, and later resurgence after
experience of drinking with others can also initial control. COVID-19 transmission on
be a key motivation for engaging in such the East Coast of the U.S., for example, was
activities. In each of these contexts, alcohol initially fueled by a large private party in
consumption may provide the primary Connecticut54 and a biotechnology confer-
rationale for attending settings where alcohol ence in Massachusetts55. The resurgence of
is available (i.e., going to a bar to drink) and/ COVID-19 in many countries has been linked
or an exacerbating factor tightly linked (i.e. to the re-opening of bars and nightclubs,
readily available) to settings where individu- music festivals, motorcycle rallies, and cam-
als seek out social engagement (e.g., weddings pus parties with the resumption of college,
or large private gatherings). among other examples. Conversely, closing or
We can consider the act of attending a restricting access to bars and nightclubs has
nightclub as an example of a high risk social been linked to significant declines in trans-
behaviour in which alcohol plays a central mission and slowed community spread.56–59
role in elevating risk of COVID-19 transmis- Acute behavioral effects from alcohol and
sion. Nightclubs involve high concentrations social contexts involving the use of alcohol
of people circulating in an indoor space, (often to the point of impairment) may
ensuring relatively close proximity to a large be most impactful in terms of COVID-19
number of other individuals in a confined transmission. Nevertheless, heavy alcohol
area. Like many other shared indoor spaces use and alcohol use disorder are also worth
(including offices, hospitals, schools), ventila- considering because behavioral and socio-
tion may be poor and the rate of air exchange economic risk factors for these behaviours/
(i.e. swapping stale inside air for fresh outside conditions also appear to be risk factors for
air) may be limited.53 Those who are drinking COVID-19.60 For example, those with severe
cannot wear masks, and the disinhibiting alcohol use disorder may be more likely to
effects of alcohol may further reduce con- be poor, have chronic medical conditions,
scious social distancing behaviours. Further, smoke, and have unstable housing or live in
increasing the risk of transmission, loud noise crowded conditions such as shelters, all of
and loss of inhibition may lead drinkers to which are risk factors for incident COVID-19
move closer to one another, shouting to be infection and possibly worse outcomes among
heard, perhaps also while singing or dancing those who become infected. In addition, those
or engaging in other forms of exertion (poten- with less severe alcohol use disorders but who
tially increasing respiration rate and forced nevertheless are heavy drinkers (constituting
expiration). Furthermore, frequent physical the majority of people with alcohol use dis-
contact with other patrons and touching of orders), even in the absence of acute use, are
surfaces (table tops, bar glasses) may present more likely to be afflicted with neurodegener-
additional risk for transmission. Finally, ative conditions or mental health problems.
because most club patrons are unlikely to be Executive functioning (decision-making and
known to one another, those feeling unwell judgement) may also be affected to the extent
may be less concerned about possible COVID- that consistent engagement in protective
19 transmission than if they were attending behaviors such as maintaining social dis-
a gathering within their own social or family tancing and proper mask wearing and hand
networks. hygiene are more difficult.
16 ALCOHOL AND THE CORONAVIRUS PANDEMIC: INDIVIDUAL, SOCIETAL AND POLICY PERSPECTIVES1 EFFECTS
FIG 2 On a scale of 1 to 10, how risky is…
Opening the mail
Getting restaurant takeout
LOW RISK
Pumping gasoline
Playing tennis
Going camping
Grocery shopping
Going for a walk, run or bike ride with others
Playing golf
LOW – MODERATE
Staying at a hotel for two nights
Sitting in a doctor’s waiting room
Going to a library or museum
Eating in a restaurant (outside)
Walking in a busy downtown
Spending an hour at a playground
Having dinner at someone else’s house
Going to a beach
MODERATE RISK
Shopping at a mall
Working a week in an office building
Swimming in a public pool
Visiting an elderly relative or friend in their home
Going to a hair salon or barbershop
MODERATE – HIGH
Eating in a restaurant (inside)
Attending a wedding or funeral
Traveling by plane
Playing basketball or football
Hugging or shaking hands when greeting a friend
Eating at a buffet
Working out in a gym
HIGH RISK
Going to a movie theater or an amusement park
Attending a large music concert
Going to a sports stadium
Going to a bar
SOURCE: Texas Medical Association
ALCOHOL AND THE CORONAVIRUS PANDEMIC: INDIVIDUAL, SOCIETAL AND POLICY PERSPECTIVES 17PHOTO: LOGAN WEAVER / UNSPLASH 18 ALCOHOL AND THE CORONAVIRUS PANDEMIC: INDIVIDUAL, SOCIETAL AND POLICY PERSPECTIVES
2 ALCOHOL USE
2 Population level alcohol
use, related social harms
and the pandemic
At a whole-of-society (i.e., population) level, alcohol-related harm is expressed (e.g. less
whether or not overall alcohol use stays the public violence but more domestic violence).
same, decreases or increases during the Effects of change in availability may also vary
pandemic and into the longer-term, will across sub-populations (e.g. gender, age,
depend on a wide range of factors that will socio-economic status) depending on related
vary among drinking cultures, governments underlying risks (e.g. mental health prob-
and countries. Nevertheless, established lems) and drinking patterns (e.g. low-level
‘availability’ theory, in combination with regular use, episodic heavy drinking).
studies of how drinkers have responded to Also key to determining the pandemic’s Decades of scientific
major social upheaval or crises in the past, effect on population-level alcohol con- research point to policy
provide valuable insights into how drinker sumption are the strong inter-relationships and regulation responses
populations are likely to respond. between alcohol use, particularly heavy that can influence
Decades of scientific research point to use, psychological distress or mental health alcohol’s ‘availability’
policy and regulation responses that can problems. Substance use and mental health during the pandemic as
influence alcohol’s ‘availability’ during the problems co-occur frequently and it has been fundamental to deter-
mining the direction and
pandemic as fundamental to determining argued that effective treatments and preven-
magnitude of change
the direction and magnitude of change in tion strategies need to consider both aspects
in alcohol consumption
alcohol consumption and related harms at a of the relationship in order to be effective.e.g. 64 and related harms at a
population level.61–63 There are both economic It is likely, therefore, that the extent to which population level.
and physical aspects to alcohol availability. the pandemic exacerbates pre-existing mental
All else being equal, economic availability is health problems or leads to newly emerged
higher when retail prices are lower relative problems, will also have considerable bearing
to disposable income (i.e. alcohol is more on population alcohol use, although not nec-
affordable). Physical availability is higher essarily in a manner that is evenly distributed
when ease of access is greater such as when among sub-populations.
numbers of outlets increase or hours of sale Two recent studies support the importance
are extended. When availability changes also of economic and physical alcohol availability
affect where and how alcohol is consumed as well as mental health concerns in deter-
(e.g. by shifting drinking from bars to homes), mining the pandemic’s effects on population
then it can also lead to changes in how level alcohol consumption. De Goeij et al.
ALCOHOL AND THE CORONAVIRUS PANDEMIC: INDIVIDUAL, SOCIETAL AND POLICY PERSPECTIVES 192 ALCOHOL USE
(2015)65 and Rehm et al. ( 2020)66 examined 2.1 Population-level alcohol consump-
impacts of past economic (e.g. recessions) tion before and after the pandemic
and public health (e.g. the SARS outbreak)
Pre-COVID-19, between 1990 and 2017, per-
crises on population level alcohol use. They
adult global alcohol consumption increased
identified psychological distress, level of
substantially by 10% (5.9 L pure alcohol to
income/budgetary constraints, and changes
6.5 L). Manthey et al (2019)67 predicted that
to price and/or physical availability of alcohol
the upward trend would continue, and that by
as key predictors of consumption. In relation
2030, global consumption would increase by
to the COVID-19 pandemic therefore, a range
a further 17%, reaching 7.6 L. The prevalence
of outcomes are possible depending on how
of current drinkers was also projected to
and in what combination, these key ‘mech-
rise (45% in 1990 to 50% in 2030), while
anisms’ are engaged. For instance, elevated
the prevalence of lifetime abstainers was
psychological distress in a community may
expected to decline (46% to 40%). Prior to the
lead to some increasing their alcohol use, but
pandemic, therefore, it was clear that world-
this may be countered by an overall reduction
wide numbers of drinkers and total alcohol
in physical access to alcohol through alcohol
consumption were on the rise.
sales bans or an overall increase in price.
Alcohol use causes a substantial burden
Another scenario might involve shutting
of global mortality and morbidity68, the true
down all on-trade functions of bars and res-
extent of which may not yet have been fully
taurants (i.e. dine-in food and alcohol service)
realized.45,69 Further increases in total and
while, at the same time, lifting their off-trade
per-capita use will, in all likelihood, present
alcohol sales restrictions. This would effec-
further challenges for public health, safety
tively increase the total number of off-trade
and the burden that alcohol places on society.
outlets, as pubs and restaurants are enabled
Further, as discussed previously in this
to sell alcohol via take-away and home
report, due to its various physiological and
delivery services, with or without provision of
behavioral effects – heavy use and intoxi-
food. This might only lead to a slight increase
cation in particular – alcohol may increase
in consumption overall but a large increase in
vulnerability to COVID-19 infection, severity
the amount of alcohol consumed in the home.
and enhance transmission of the virus.
At the present time and based on available
data, it is premature to conclusively deter-
FOTO: OSCAR SODERLUND / UNSPLASH
mine, or to easily characterize, how total
consumption or patterns of use have changed
during the pandemic. What is almost certain,
however, is that there will be substantial
variability in how populations respond
depending on the form and magnitude of the
key mechanisms described above.
Documentation and analysis of the impacts
of the pandemic on alcohol consumption
levels and patterns are complicated by wide
variations in pre-pandemic consumption
levels and drinking patterns between regions.
Interpretation also needs to take account of
variations within regions by gender, age and
a raft other factors including the extent to
which COVID-19 has impacted on social and
economic functioning. In addition, in any one
20 ALCOHOL AND THE CORONAVIRUS PANDEMIC: INDIVIDUAL, SOCIETAL AND POLICY PERSPECTIVES2 ALCOHOL USE
location, consumption may shift over time due demographic, socio-economic and geographic
to changes in alcohol policies. On a more fun- differences among respondents, it was the
damental level, capacity to examine COVID-19 presence of psychological distress since the
effects on population level alcohol use will advent of the pandemic that most strongly
depend heavily on how alcohol consumption predicted increased alcohol use.77 Recent
is measured (e.g., independently reported alco- accounts from Scotland concur regarding the
hol sales data vs. self-report survey data), the association between pandemic-related stress
quality and timeliness of the data and indeed, and increased alcohol use, particularly among
whether data are available at all. vulnerable drinkers, i.e. people who already
drank at higher levels before the pandemic.78
Self-report surveys Commentary from local health and research
The development of consumption varies sectors also points to increased consumption
in different parts of the world. For some being facilitated by increased physical
people isolation, boredom and anxiety have availability of alcohol in the form of heavily
led to increased drinking where alcohol marketed off-trade sales and unfettered home
has still been available. For others the loss delivery services.79 A nation-wide survey of
of income and reduced access to alcohol 3,000 U.S. employees working from home
has led to reduced consumption. Alcohol reported that about one third believed they
consumption surveys during the pandemic would drink more alcohol during lockdown or
have largely focused on whether respondents self-isolation than under normal conditions.
have increased or decreased their drinking in A similar proportion said that when working
recent times. Although these data preclude from home they were more likely to drink
conclusions regarding quantitative assess- alcohol during work hours compared to their
ments of population-level alcohol use and usual work place.80
tend to be from high-income countries, they
are nonetheless informative. Surveys have Alcohol sales
largely shown a higher percentage of respond- Beyond surveys, alcohol sales data (where
ents increasing their drinking, as opposed available), also provide an avenue for
to decreasing. For example, in Canada (20% identifying potential consumption changes.
increasing v. 10% decreasing), Germany (35% Official national sales data are typically
v. 19%), the U.S. (39% v. 12%) and the U.K. reported annually, and are therefore not yet
(43% v. 15%).70–73 The Global Drug Survey74 available for the pandemic period. However,
also reported increased consumption by 36% some information can be gleaned from
of respondents and decreased consumption industry documents such as volume-based
by 22%, although available data were scarce sales reports of two large alcohol companies,
and limited to 20 countries with generally AB InBev and Diageo. According to interim
high-income. Conversely, an online survey reports for the six months ending June 2020,
conducted in nine European countries AB InBev incurred a 13% decrease in alcohol
reported 36% of respondents had decreased volume sold compared to the same period in
alcohol use and less than 10% had increased.75 the previous year.81 Diageo reported a similar
Similar results were found for Norway.76 decline of 11% in sales volume.82 It is difficult
In Australia, self-reported changes to infer changes to total alcohol consumption,
in consumption tended overall towards as alcohol users may pivot to cheaper or unre-
increased use, and were much larger for corded forms of alcohol. These sales-based
women than for men. For women, caring for declines differed substantially by region. AB
dependent children was a major predictor of InBev, for instance, reported a 3% decline
increased alcohol use, whereas for males, loss in North America and a 22% decline in Asia
of employment or reduced work hours were Pacific. Likewise, Diageo’s North American
predictive. However, accounting for a range of sales indicated the greatest stability, dropping
ALCOHOL AND THE CORONAVIRUS PANDEMIC: INDIVIDUAL, SOCIETAL AND POLICY PERSPECTIVES 212 ALCOHOL USE
only 1% compared to declines of 30% or more facilitated by rapid emergence of wide-spread
in all other global regions. home-delivery services. Reports in the UK,89
In Sweden, recorded sales from the retail US and Australia88 indicate online sales
monopoly Systembolaget increased by about increases beyond 200%. For some regions,
12% in the January-June period83, however, these newly emerged modes of sale are
there was also a large drop in unrecorded entirely novel, such as take-away service
sales (such as personal imports). Overall from bars and restaurants in areas where
consumption is estimated to have decreased home delivery was not previously available,
by 7% during March and April.84 Both the e.g. West Bengal in India has begun allowing
Norwegian and Finnish alcohol monopolies alcohol delivery services. In Sweden too, a
have reported large off-trade sales increases, number of municipalities have permitted
but in Finland this has been balanced by licensed outlets to provide take-away alcohol,
much less drinking in on-trade locations, in conflict with current alcohol legislation90;
such as bars and restaurants.76,85 decisions from the courts are pending.
Country-specific sales data provide In summary, as expected, impacts of the
snapshots of alcohol purchasing patterns, pandemic on alcohol consumption across
but short time periods undermine their regions have been variable – in keeping with
usefulness as sold alcohol may not be equally variable responses by government
immediately consumed. In many countries decision makers, pre-pandemic drinking
where there was a possibility of liquor stores patterns and societal norms. There is also
Also central to being deemed ‘non-essential’ a temporary, emerging evidence of divergence among
any consideration large sales peak was observed that likely drinker groups within regions related
represents a stockpiling effect. Reports from to pre-pandemic drinking patterns and
of the extent to March 2020 show large increases in weekly psychological distress. Perhaps of greatest
which alcohol sales compared to previous years, e.g. +54% importance, however, will be how these
contributes to in the UK86, +40% in Canada87, +34% in changes play out in the longer term. The
the total health Australia88 and +55% in the U.S.88 However, most significant long-run changes in alcohol
in most cases sales fell back to approximately consumption and related harms are likely to
burden on society historical levels after initial panic buying had be driven by changes to alcohol policy that
is the degree of ceased. have occurred in response to the pandemic.
burden that these This will be particularly true in cases where
Modes of sale and access to alcohol
outcomes incur regulatory polices loosened ‘temporarily’
As above, at this point in the pandemic, it is during the pandemic are not swiftly returned
to public health difficult to definitively discern whether alco- to pre-pandemic status.
services. hol consumption has increased, decreased
or perhaps even remained stable in a given 2.2 Alcohol-related social harms
population. That said, in many countries Many harms related to alcohol use extend
there have been obvious changes to the ways well beyond the physical health and wellbeing
in which alcohol can be accessed, at least of the drinker and this is no less true in the
temporarily, and the locations where it can be context of the COVID-19 pandemic. Alcohol-
consumed. related social harms are a function both
Many lockdowns have included closure of of the amount of alcohol consumed, and
on-trade outlets (bars and restaurants) and physical and social contexts in which that
shifted purchasing towards off-trade outlets consumption occurs. Alcohol-related harms
(take-away shops). This has correspondingly are typically conceptualized as having a strong
shifted drinking away from on-trade venues social aspect including such outcomes as
and into private residences. There have been interpersonal violence, domestic violence,
reports of very large online sales increases child neglect and abuse, pre-natal alcohol
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