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Solving the pandemic’s drinking problem

The Covid-19 lockdown has changed alcohol habits, but public health researchers face a blurred and incoherent picture of who’s been drinking, and how much

David Adam • knowable
March 15, 2021 20 minSource

Solving the pandemic’s drinking problem

The Covid-19 lockdown has changed alcohol habits, but public health researchers face a blurred and incoherent picture of who’s been drinking, and how much

3.15.2021

Sourdough and baking helped many people cope with 2020, and many have found solace in family Zoom calls. But for millions around the world, the stress of the pandemic and tedium of lockdown life saw them seek the comforting embrace of another, fickle friend: alcohol.

Like most social behaviors, drinking habits have been upended by pandemic restrictions. With people furloughed and working from home, wine bottles have been opened earlier and earlier in the day. But one major role of booze in normal times is to act as a social lubricant, and with bars and pubs closed and parties banned, other drinkers have simply lost the taste for it.

So has Covid-19 got us drinking more, or less, than before? Public health researchers are trying to find out — to see if the events of 2020 have helped the world to sober up, or if we’re all heading for the mother of all hangovers. They’re finding that age and outlook on life drive our response to lockdown. Younger drinkers seem happier to find other things to do, while their stressed-out parents are more likely to be seeking solace in the bottom of a glass.

And, surprise, surprise, it looks like we British have reacted to Covid-19 by drinking the most.

“The overall picture is just really messy,” says Colin Angus, an alcohol policy modeler at the University of Sheffield Alcohol Research Group in the UK. “Some people are going to be behaving in different ways to others. And that’s going to vary by demographic factors but also by geography.”

Data from the UK highlight this blurred picture. In May last year, a survey that asked more than 20,000 people about alcohol consumption in 2019 and 2020 found a spike in high-risk drinking following lockdown, from around 25 percent to 38 percent. But the same survey reported a near doubling in the number of high-risk drinkers who said they were trying to cut down, up to nearly 29 percent from 15 percent.

A separate survey of 33,000 people carried out around the same time found that 48 percent of drinkers said they were drinking about the same amount. The rest were split equally between those who said they were drinking more and those who said they were drinking less.

Survey after survey in different countries and regions finds this same picture, says Henk Hendriks, a nutrition consultant in Zeist, the Netherlands, who wrote an article on alcohol and human health in the Annual Review of Food Science and Technology last year. “About half of people report they are drinking about the same amount as before, while about a quarter drink less and a quarter say they are drinking more,” he says.

Scientists who track large-scale trends in alcohol consumption tend to take such survey results with a healthy dose of salt and vinegar. With bars closed, drinkers often indulge differently — for example, many people in the UK choose to drink beer when out in pubs but wine at home, Angus says. This can make it difficult for people asked in surveys to accurately compare the overall amount of alcohol they drank during lockdown at home with what they drank, say, six months or a year previously.

“People are really bad at that. It often gets painted as ‘People are lying,’ but it’s just genuinely quite hard to answer that question,” Angus says. “We drink in quite a chaotic way.”

In search of more reliable data, Angus turned instead to information on alcohol duty provided to tax authorities by retailers. “HM Revenue and Customs data is as close to gold standard as we can get,” he says. “It’s pretty hard to cheat the tax man.” Based on tax data, Angus says the most likely scenario is that total alcohol consumption probably dropped around the time of the first lockdown in the spring, driven by a collapse in beer sales when pubs closed. But subsequently UK drinkers more than made up for it, especially as home drinkers opened more bottles of wine and spirits through the summer. Overall, he thinks the pandemic increased UK alcohol consumption by a pretty significant 3 percent.

What about other places? International surveys are the most plausible way to compare across borders and one of the biggest is run by a team of European scientists, including clinical psychologists at the Technical University of Dresden in Germany. Between April and July 2020, the project surveyed more than 30,000 people across 21 European countries. It asked them about changes to their drinking habits in the previous month: how frequently they drank, how much they consumed when they did so, and how often they binged, defined as six or more drinks in a session.

The results are subject to bias from the shaky recall of participants and because, as with many online surveys, those who respond are unlikely to fairly represent the national populations. But they do suggest the British could be unusual in drinking more when faced with the initial lockdown. The UK was the only country to report an increase in overall drinking. Ireland showed no change, while alcohol consumption in every other nation surveyed fell significantly. 

Some unusual evidence supports this continental decline. Forensic scientists analyzed the wastewater flushed away by the citizens of the Austrian city of Innsbruck and found that levels of ethyl sulfate — a metabolite of alcohol — dropped sharply after lockdown. The change corresponds to about a 20 percent decrease in drinking, the study concludes.

A more global survey led by psychiatrists at the UK’s University of Cambridge and including  1,346 people across 83 countries found the same picture: While overall weekly drinking during quarantine remained about the same or was reduced in the US, Canada and other nations, the UK reported an increase.

The European survey calls the increased drinking in the UK an “alarming anomaly.” It could be down to particularly high levels of distress in response to the pandemic, the scientists suggest, combined with a culture that more widely embraces alcohol as a coping strategy.

Britain has long had a notoriously problematic relationship with alcohol. Back in 1862, the Russian novelist Fyodor Dostoyevsky wrote that in London “everyone is in a hurry to drink himself into insensibility.” And amid the slaughter of World War I, David Lloyd George — then chancellor and later prime minister — warned that: “Drink is doing us more damage in the war than all the German submarines put together.”

Indeed, the authors of the European survey wryly observe, “It is worth mentioning that the UK seems to be the only European country where liquor stores were added to the list of ‘essential’ businesses allowed to remain open during the early stages of lockdown, along with pharmacies and supermarkets, with alcohol deemed to be an ‘essential’ good during the crisis.” (See box.)

Labeling alcohol this way is a mistake, says Maristela Monteiro, senior advisor on alcohol and substance abuse with the Pan American Health Organization (PAHO) in Washington, DC. “Alcohol is not an essential product. It is not a healthy product,” she says. To award alcohol such a status could have a damaging aftereffect, she adds, with children and young adults exposed to the idea that drinking is an essential part of life.

Earlier this year, figures from the UK Office for National Statistics showed that deaths directly caused by alcohol reached an all-time high last year. From January to September 2020, England and Wales registered 5,460 fatalities from diseases caused by alcohol misuse, up 16 percent from the same period in 2019 and the highest since records began in 2001, though the long-term effects are not yet clear. “It will take time before the impact the pandemic has had on alcohol-specific deaths is fully understood,” Ben Humberstone of the ONS said in a public statement.

For public health experts, overall levels of drinking are less important than changes among those people who are drinking the most. And surveys across countries offer a fairly consistent pattern on that question, too. Those people who didn’t drink much anyway have cut down their consumption or drink about the same. And those who already drank the most have upped their alcohol intake further.

“We are seeing a real polarization,” says Emily Nicholls, an alcohol researcher at the University of Portsmouth, UK. For example, 43 of 182 patients registered with a London alcohol clinic who were contacted by researchers in May and June of 2020 said they were drinking more than before lockdown. The strongest predictor of increased consumption — more than age, mood or social circumstances — was higher pre-lockdown drinking, the researchers found.

Many surveys don’t typically ask people why they feel they are drinking more or less, just whether they are. But some data do offer clues. Reduced alcohol availability and income are associated with lower consumption. A survey of more than 12,000 people across Latin America and the Caribbean, carried out in May and June by Monteiro at PAHO and her colleagues, showed that household income was closely associated with the likelihood of increased heavy episodic drinking, with high earners twice as likely as the lowest paid to increase their drinking.

Drinking behavior in lockdown is also influenced by age — and in a surprising way. Studies in Belgium suggest that while younger people — college students, for example — cut down on average when stuck at home, the generation of their middle-aged parents started to drink more. Pierre Maurage, a psychologist at the Louvain Catholic University in Belgium, and his colleagues asked 1,951 college students (average age 22) about their drinking habits before and during lockdown, and found that most drank less during lockdown. Even previously heavy drinkers cut back significantly — by more than 12 units a week, on average.

These changes occur because college students tend to drink for social reasons, using alcohol to improve their mood and relationships. When they could no longer socialize, many simply stopped drinking as much. “The main reason they give for reducing consumption is that, ‘I don’t have any reason to drink because I’m drinking with friends or family or parents, and I don’t have these occasions anymore,’” Maurage says. “That’s interesting, because many people think that binge-drinking students are going to be alcohol dependent and can’t control their consumption. Actually, they do. They can stop when they have no more motivation to drink.”

In contrast, when Maurage’s team gave the same survey to 7,711 people from the general population, they found that many older Belgians who were usually moderate drinkers said they were having more. So were those who reported stress caused by fear of catching the virus, and those who drank to cope with such stress. These are the people who worry alcohol researchers the most, because they risk turning a bad habit into a serious problem.

The pandemic is highlighting the scale of the issue. A survey of nearly 2,000 people in lockdown in the US carried out by researchers at the University of Texas showed that about a third reported binge drinking during the pandemic, defined here as at least one occasion when men had five drinks or more, and women four drinks or more, in two hours. Binge drinkers were more than twice as likely to have increased their drinking: 60 percent of them said consumption was up during the pandemic, compared to 28 percent of the non-binge drinkers. This matches the results of other studies, which suggest that heavy drinkers, and especially those with alcohol use disorder, are more likely to try to cope with the increased stress of the pandemic by turning to alcohol.

Binge drinkers diagnosed with depression were more likely to report consuming more alcohol during the pandemic, the Texas study showed. And the longer people were stuck at home under lockdown conditions, the more likely they were to try to cope with the stress this caused by binge drinking.

So how many drinks are too many? “There’s nothing necessarily wrong with having one drink with dinner and helping to relax and stimulating the conversation with the family,” says George Koob, director of the US National Institute on Alcohol Abuse and Alcoholism. “It’s when you start depending on that, as opposed to other mechanisms for winding down. And then you try to keep doing it because tolerance develops so quickly to alcohol. People forget that.”

Drinking in lockdown is particularly problematic, Koob says, because the social isolation of physical-distancing measures encourages low moods, loneliness and malaise. And indeed, surveys across the world have suggested that more people complain of anxiety and depression during lockdown periods. A study of about 3,000 adults in the UK, for example, found that 64 percent of participants reported symptoms of depression and 57 percent reported symptoms of anxiety in the first six weeks of last year’s social restrictions.

Scientists have yet to unravel the exact biological mechanisms that drive addiction, so it’s not clear which moderate drinkers could head down the slippery slope to a full-blown problem during lockdown. Koob argues that using alcohol to cope with stress from lockdown restrictions typically creates more stress, which encourages more drinking and so locks people into a psychological cycle of self-destruction.

People who turn to drink to cope with the stress of Covid-19 are vulnerable to an effect called hyperkatifeia, he adds, in which withdrawal symptoms mimic effects of stress such as anxiety, irritability and sleep disturbance — the same things that encourage people to drink more in the first place. It’s hard to test this idea, though some studies do agree that problem drinkers tend to develop a problem because they are trying to avoid negative feelings — like those caused by stress and alcohol withdrawal — rather than because they are chasing positive feelings.

Long-term heavy drinking also releases higher amounts of the chemicals cortisol and adrenocorticotropic hormone into the bloodstream. This shift in hormonal balance affects the way the body perceives and responds to stress. That means a long-term heavy drinker may experience higher levels of anxiety when faced with a stressful situation than someone who never drank or who drank only moderately.

Indeed, in a 2009 study, researchers at Yale University found that alcohol-dependent people reacted differently than social drinkers when they were asked to listen to descriptions of stressful situations, such as losing a job or ending a relationship. The heavy alcohol users showed significant increases in heart rate and salivary cortisol. These physiological signs of anxiety were accompanied by a powerful craving for alcohol.

“Negative emotional states are a key part of addiction. I’ve never met an individual with a severe alcohol use disorder who’s tiptoeing through the tulips,” Koob says. “They’re basically miserable, and for a long time, people in the addiction field forgot about the misery part.”

Koob says that some impacts of the pandemic on drinking behaviors are likely to linger. History shows that many people continue to drink more after previous stressful episodes: US health officials saw it among New Yorkers after the 9/11 terrorist attacks. And more than a third of 209 surveyed survivors of Hurricane Katrina reported having six or more drinks on one occasion at least monthly, more than double the average for the state. “We’re trying to prepare for that,” he says. “I just hope that this too will pass, and people will be so engaged into reconnecting with other people — which is really a great substitute.”

This article is part of Reset: The Science of Crisis & Recovery , an ongoing Knowable Magazine series exploring how the world is navigating the coronavirus pandemic, its consequences and the way forward. Reset is supported by a grant from the Alfred P. Sloan Foundation. 

This article originally appeared in Knowable Magazine, an independent journalistic endeavor from Annual Reviews. Sign up for the newsletter.

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