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High-Risk Drinking in Midlife Before Versus During the COVID-19 Crisis: Longitudinal Evidence From the United Kingdom

Open AccessPublished:November 21, 2020DOI:https://doi.org/10.1016/j.amepre.2020.09.004

      Introduction

      Emerging evidence suggests that the COVID-19 pandemic and associated lockdown restrictions may have influenced alcohol consumption. This study examines changes in high-risk alcohol consumption from before to during the COVID-19 crisis in an established cohort of middle-aged British adults.

      Methods

      Participants consisted of 3,358 middle-aged adults from the 1970 British Cohort Study who completed the Alcohol Use Disorders Identification Test for detecting hazardous drinkers in primary care settings in 2016–2018 (when aged 46–48 years) and May 2020 (aged 50 years). Multivariable logistic regression analysis was used to examine changes in high-risk drinking (scores of ≥5), and multinomial regression was used to compare responses with individual test items in 2016–2018 and May 2020.

      Results

      Among middle-aged British adults, high-risk drinking increased by 5.2 percentage points from 19.4% to 24.6% (p<0.001) between 2016–2018 and May 2020. The increase in high-risk drinking was not moderated by sex, marital status, educational attainment, the presence of a chronic illness, or the year the baseline survey was completed. The prevalence of drinking ≥4 times a week doubled from 12.5% to 26% from before to during the pandemic (p<0.001), and there was also evidence of an increase in the frequency of being unable to stop drinking.

      Conclusions

      This study provides evidence linking the COVID-19 crisis and associated lockdown restrictions to an increase in high-risk drinking patterns and particularly frequent drinking in British adults. Potential long-term changes in drinking habits should be monitored following the emergence of the COVID-19 pandemic.

      INTRODUCTION

      The coronavirus disease 2019 (COVID-19) pandemic and stay-at-home orders and social distancing measures have dramatically changed daily life for much of the world's population. Although such containment strategies have been successful in reducing the impact of COVID-19 on mortality, they have also brought severe economic consequences and have been associated with a rise in isolation and psychological distress, which may contribute to increased alcohol consumption.
      • Rodriguez LM
      • Litt DM
      • Stewart SH
      Drinking to cope with the pandemic: the unique associations of COVID-19-related perceived threat and psychological distress to drinking behaviors in American men and women.
      In the United Kingdom (UK), pubs, bars, and restaurants and other nonessential businesses were closed for >3 months between late March and early July 2020. During this period, retail sales of alcoholic beverages rose sharply raising concerns that alcohol misuse may have increased.
      • Finlay I
      • Gilmore I
      COVID-19 and alcohol-a dangerous cocktail.
      ,
      • Barry AE
      • King J
      • Sears C
      • Harville C
      • Bondoc I
      • Joseph K
      Prioritizing alcohol prevention: establishing alcohol as the gateway drug and linking age of first drink with illicit drug use.
      This is particularly concerning because alcohol misuse is linked to subsequent polydrug use,
      • Enos G
      Effects on lung, immune function offer warning for drinking in crisis.
      can reduce immunity to viral infections, and may amplify the risk of severe illness for those infected by COVID-19.
      • Barry AE
      • King J
      • Sears C
      • Harville C
      • Bondoc I
      • Joseph K
      Prioritizing alcohol prevention: establishing alcohol as the gateway drug and linking age of first drink with illicit drug use.
      ,
      • Testino G
      Are patients with alcohol use disorders at increased risk for COVID-19 infection?.
      However, to date, evidence of the potential impact of the COVID-19 crisis on drinking behavior is limited.

      Koopmann A, Georgiadou E, Kiefer F, Hillemacher T. Did the general population in Germany drink more alcohol during the COVID-19 pandemic lockdown? Alcohol Alcohol. In press. Online June 19, 2020. https://doi.org/10.1093/alcalc/agaa058.

      In initial studies, a substantial portion of sampled Chinese (32%), Australian (26.6%), German (34.7%), and UK (28%) adults reported drinking more alcohol during the COVID-19 pandemic and lockdown than previously,

      Koopmann A, Georgiadou E, Kiefer F, Hillemacher T. Did the general population in Germany drink more alcohol during the COVID-19 pandemic lockdown? Alcohol Alcohol. In press. Online June 19, 2020. https://doi.org/10.1093/alcalc/agaa058.

      • Stanton R
      • To QG
      • Khalesi S
      • et al.
      Depression, anxiety and stress during COVID-19: associations with changes in physical activity, sleep, tobacco and alcohol use in Australian adults.
      • Sun Y
      • Li Y
      • Bao Y
      • et al.
      Brief report: increased addictive internet and substance use behavior during the COVID-19 pandemic in China.

      Robinson E, Gillespie S, Jones A. Weight‐related lifestyle behaviours and the COVID‐19 crisis: an online survey study of UK adults during social lockdown. Obes Sci Pract. In press. Online July 24, 2020. https://doi.org/10.1002/osp4.442.

      but these studies did not use validated measures of alcohol use and relied on retrospective recall. Furthermore, a cross-sectional survey of UK adults found a higher prevalence of high-risk drinking during lockdown than before the pandemic,

      Jackson SE, Garnett C, Shahab L, Oldham M, Brown J. Association of the Covid-19 lockdown with smoking, drinking, and attempts to quit in England: an analysis of 2019-2020 data. Addiction, 2020. https://doi.org/10.1111/add.15295.

      and a longitudinal study of UK and U.S. adults identified a marked increase in drinking alcohol ≥4 times a week and heavy episodic drinking from before to during the COVID-19 crisis.

      Daly M, Robinson E. Problem drinking before and during the COVID-19 crisis in US and UK adults: evidence from two population-based longitudinal studies [preprint]. medRxiv. Posted June 28, 2020. https://doi.org/10.1101/2020.06.25.20139022.

      Although these studies are suggestive of an increase in problem drinking, there is a need for research that examines longitudinal changes in alcohol consumption using validated measures of high-risk drinking. This study examines drinking behavior among middle-aged adults in 2016–2018 and May 2020 when lockdown restrictions were in place throughout the UK.

      METHODS

      This study used data from the 1970 British Cohort Study (BCS), a prospective cohort study of 17,000 children born in Britain in 1970. In May 2020, a total of 10,458 BCS participants were invited to take part in a COVID-19 online survey and 4,223 participated (response rate of 40.4%). This study draws on data from those who took part in both the COVID-19 survey and the 2016–2018 wave of the BCS (N=3,358). The BCS study received ethical approval from the National Research Ethics Service. In all analyses, survey weights were applied to align the characteristics of the COVID-19 survey respondents with those of the representative sample of BCS participants born in 1970.
      • Brown M
      • Goodman A
      • Peters A
      • et al.
      COVID-19 survey in five national longitudinal studies: wave 1 user guide (version 1).
      The Alcohol Use Disorders Identification Test (AUDIT) for detecting hazardous drinkers in primary care settings (AUDIT-PC)
      • Piccinelli M
      • Tessari E
      • Bortolomasi M
      • et al.
      Efficacy of the alcohol use disorders identification test as a screening tool for hazardous alcohol intake and related disorders in primary care: a validity study.
      was used to screen for potentially harmful alcohol consumption.
      • Kim JW
      • Lee BC
      • Lee DY
      • et al.
      The 5-item Alcohol Use Disorders Identification Test (AUDIT-5): an effective brief screening test for problem drinking, alcohol use disorders and alcohol dependence.
      The AUDIT-PC correlates very strongly with the 10-item AUDIT (r≥0.95)
      • Kim JW
      • Lee BC
      • Lee DY
      • et al.
      The 5-item Alcohol Use Disorders Identification Test (AUDIT-5): an effective brief screening test for problem drinking, alcohol use disorders and alcohol dependence.
      and has shown high levels of sensitivity and specificity in detecting alcohol use problems (0.84–0.94).
      • Piccinelli M
      • Tessari E
      • Bortolomasi M
      • et al.
      Efficacy of the alcohol use disorders identification test as a screening tool for hazardous alcohol intake and related disorders in primary care: a validity study.
      ,
      • Meneses‐Gaya C
      • Zuardi AW
      • Loureiro SR
      • et al.
      Is the full version of the AUDIT really necessary? Study of the validity and internal construct of its abbreviated versions.
      For the COVID-19 survey, the AUDIT-PC was adapted by adding Since the start of the Coronavirus outbreak to the start of each item. Those who indicated that they did not consume an alcoholic drink in response to the first AUDIT-PC question (nondrinkers) were assigned a score of 0. Participants were classified into 2 groups: (1) nondrinkers and unproblematic drinkers (scores of 0–4 on the AUDIT-PC) and (2) high-risk drinkers (scores of ≥5).
      All analyses were adjusted for baseline characteristics: sex, marital status (married versus not married), educational qualifications (third-level qualification such as a diploma, degree, or higher degree versus no third-level qualification), whether participants have been diagnosed with a chronic mental or physical health condition, and the year the 2016–2018 baseline survey was completed.
      First, the change in high-risk drinking levels from 2016–2018 to May 2020 was examined in a logistic regression model with SEs clustered by the individual participant identifier. Next, the survey wave variable was interacted with each background characteristic to identify whether changes in high-risk drinking differed by subgroup. Finally, changes in individual AUDIT-PC item responses between 2016–2018 and May 2020 were examined using multinomial logistic regression.

      RESULTS

      Overall AUDIT-PC scores increased from 3.17 (SD=2.46) to 3.34 (SD=2.77) between baseline and follow-up (p=0.003). An increase in the prevalence of high-risk drinking from baseline to follow-up was observed across all examined groups (Table 1). Logistic regression analyses showed that high-risk drinking increased from 19.4% to 24.6% between 2016–2018 and May 2020, a statistically significant increase of 5.2 percentage points (95% CI=2.5, 8.0, p<0.001), which equates to a 27% increase. This increase was not moderated by participant's sex, marital status, and educational attainment, the presence of a chronic health condition, or the year the baseline survey was completed.
      Table 1Sample Characteristics and Changes in the Prevalence of High-Risk Drinking From Before (2016‒2018) to During the COVID-19 Crisis (May 2020) in the 1970 British Cohort Study
      High-risk drinkingΔ High-risk drinking
      VariableSample characteristics2016‒2018May 20202016/2018–May 2020
      %%%% (95% CI)
      Overall sample19.324.65.2⁎⁎⁎ (2.4, 8.0)
      Male50.024.729.95.2* (0.5, 10.0)
      Female50.014.019.25.2⁎⁎⁎ (2.3, 8.1)
      Married59.119.124.65.4⁎⁎⁎ (2.3, 8.6)
      Not married40.919.724.64.9 (‒0.1, 9.9)
      Third-level qualification31.520.527.06.5⁎⁎⁎ (2.7, 10.3)
      No third-level qualification68.518.823.54.6* (1.0, 8.3)
      Chronic illness37.917.923.25.2* (0.4, 10.0)
      No chronic illness62.120.225.45.2⁎⁎ (1.8, 8.6)
      Baseline survey year
       201627.321.826.64.8 (−0.2, 9.8)
       201734.418.322.64.3 (−0.8, 9.5)
       201838.318.524.86.3⁎⁎ (2.0, 10.6)
      Note: Boldface indicates statistical significance (*p<0.05; ⁎⁎p<0.01; ⁎⁎⁎p<0.001).
      Estimates are derived from weighted data. N=3,358, observations=6,716.
      An examination of the individual AUDIT-PC items identified a 13.5 percentage point (p<0.001) increase in the prevalence of drinking ≥4 times per week (Table 2) from 12.5% to 26%, which equates to a 108% increase. There was also a small increase in the frequency of not being able to stop drinking on a weekly (1.9% increase) or daily (1.3%) basis and a shift toward consuming 1–2 alcoholic drinks (9.1%) (Table 2). When both the frequency of drinking and the number of alcoholic drinks typically consumed when drinking were considered simultaneously, there was an overall increase in alcohol consumption from baseline (mean=2.71) to follow-up (mean=2.82) (b=0.11, SE=0.03, p<0.001).
      Table 2Regression Estimates of Percentage Point Changes in Responses to AUDIT-PC Items From Before (2016‒2018) to During the COVID-19 Crisis in the 1970 British Cohort Study
      Response to AUDIT-PC item
      01234
      AUDIT item refers toB (SE)B (SE)B (SE)B (SE)B (SE)
      How often consumed alcohol
      Responses: 0=Never, 1=Monthly or less, 2=2‒4 times per month, 3=2‒3 times per week, 4=4+ times per week.
      4.3⁎⁎ (1.6)−7.6⁎⁎⁎ (1.3)−8.7⁎⁎⁎ (1.6)−1.5 (1.6)13.5⁎⁎⁎ (1.3)
      Number of standard drinks
      Responses: 0=1−2 drinks, 1=3−4 drinks, 2=5−6 drinks, 3=7−9 drinks, 4=10+ drinks.
      9.1⁎⁎⁎ (1.8)−5.3⁎⁎ (1.6)−2.9⁎⁎ (1.1)−0.6 (0.4)0.2 (0.4)
      How often unable to stop
      Responses: 0=Never, 1=Less than monthly, 2=Monthly, 3=Weekly, 4=Daily/almost daily.
      0.3 (1.1)−2.9⁎⁎⁎ (0.7)−0.6 (0.6)1.9⁎⁎⁎ (0.5)1.3* (0.5)
      How often failed to do what was expected
      Responses: 0=Never, 1=Less than monthly, 2=Monthly, 3=Weekly, 4=Daily/almost daily.
      3.0⁎⁎⁎ (0.6)−3.0⁎⁎⁎ (0.6)0.0 (0.2)0.0 (0.2)0.0 (0.0)
      Others concerned about drinking
      Responses: 0=No, 2=Yes, but not in the past year (Note: this second response option was omitted from the COVID-19 survey, so responses to this question from 2016 to 2018 were used to capture whether participants had experienced such concerns), 4=Yes, during the past year (2016‒2018 survey)/Yes, since the start of the coronavirus outbreak (2020 survey). AUDIT, Alcohol Use Disorders Identification Test; AUDIT-PC, Alcohol Use Disorders Identification Test for detecting hazardous drinkers in primary care settings.
      −1.6 (1.1)2.0* (1.0)−0.4 (0.7)
      Note: Boldface indicates statistical significance (*p<0.05; ⁎⁎p<0.01; ⁎⁎⁎p<0.001).
      Estimates are from marginal effects calculated after a multinomial logistic regression clustered by the individual participant identifier and controlling for covariates. Positive/negative coefficients indicate the percentage point increase/decrease in endorsements of the response category from 2016–2018 to May 2020.
      a Responses: 0=Never, 1=Monthly or less, 2=2‒4 times per month, 3=2‒3 times per week, 4=4+ times per week.
      b Responses: 0=1−2 drinks, 1=3−4 drinks, 2=5−6 drinks, 3=7−9 drinks, 4=10+ drinks.
      c Responses: 0=Never, 1=Less than monthly, 2=Monthly, 3=Weekly, 4=Daily/almost daily.
      d Responses: 0=No, 2=Yes, but not in the past year (Note: this second response option was omitted from the COVID-19 survey, so responses to this question from 2016 to 2018 were used to capture whether participants had experienced such concerns), 4=Yes, during the past year (2016‒2018 survey)/Yes, since the start of the coronavirus outbreak (2020 survey).AUDIT, Alcohol Use Disorders Identification Test; AUDIT-PC, Alcohol Use Disorders Identification Test for detecting hazardous drinkers in primary care settings.

      DISCUSSION

      This study examined changes in high-risk alcohol consumption before versus during the COVID-19 crisis in a nationally representative cohort of middle-aged British adults. High-risk drinking increased between 2016–2018 and May 2020, as did the prevalence of drinking ≥4 times a week. Likewise, there was evidence of an increase in the frequency of being unable to stop drinking. Rises in high-risk drinking were observed to a similar degree among men and women and those with a lower versus higher education level as well as in married versus unmarried and those with versus those without chronic illness.
      These longitudinal findings corroborate a body of largely cross-sectional research that has suggested that alcohol consumption may have increased because of the COVID-19 pandemic

      Koopmann A, Georgiadou E, Kiefer F, Hillemacher T. Did the general population in Germany drink more alcohol during the COVID-19 pandemic lockdown? Alcohol Alcohol. In press. Online June 19, 2020. https://doi.org/10.1093/alcalc/agaa058.

      • Stanton R
      • To QG
      • Khalesi S
      • et al.
      Depression, anxiety and stress during COVID-19: associations with changes in physical activity, sleep, tobacco and alcohol use in Australian adults.
      • Sun Y
      • Li Y
      • Bao Y
      • et al.
      Brief report: increased addictive internet and substance use behavior during the COVID-19 pandemic in China.

      Robinson E, Gillespie S, Jones A. Weight‐related lifestyle behaviours and the COVID‐19 crisis: an online survey study of UK adults during social lockdown. Obes Sci Pract. In press. Online July 24, 2020. https://doi.org/10.1002/osp4.442.

      Jackson SE, Garnett C, Shahab L, Oldham M, Brown J. Association of the Covid-19 lockdown with smoking, drinking, and attempts to quit in England: an analysis of 2019-2020 data. Addiction, 2020. https://doi.org/10.1111/add.15295.

      and one other longitudinal study examining both UK and U.S. adults.

      Daly M, Robinson E. Problem drinking before and during the COVID-19 crisis in US and UK adults: evidence from two population-based longitudinal studies [preprint]. medRxiv. Posted June 28, 2020. https://doi.org/10.1101/2020.06.25.20139022.

      Given that drinking is often driven by coping motives
      • Cooper ML
      • Kuntsche E
      • Levitt A
      • Barber LL
      • Wolf S
      Motivational models of substance use: a review of theory and research on motives for using alcohol, marijuana, and tobacco.
      and middle-aged adults are already at increased risk of adopting high-risk drinking patterns
      • de Vocht F
      • Brown J
      • Beard E
      • et al.
      Temporal patterns of alcohol consumption and attempts to reduce alcohol intake in England.
      ,
      • Blazer DG
      • Wu LT
      The epidemiology of at-risk and binge drinking among middle-aged and elderly community adults: National Survey on Drug Use and Health.
      but often fail to identify these practices as health damaging,
      • Blazer DG
      • Wu LT
      The epidemiology of at-risk and binge drinking among middle-aged and elderly community adults: National Survey on Drug Use and Health.
      the stress of the COVID-19 pandemic may be exacerbating problem drinking in this group.

      Daly M, Sutin AR, Robinson E. Depression reported by US adults in 2017-2018 and March and April 2020. J Affect Disord. 278;131-135. https://doi.org/10.1016/j.jad.2020.09.065.

      As such, investment in both mental health treatment programs and the provision of support for alcohol reduction is crucial. This need is highlighted by recent evidence indicating that despite an increase in high-risk drinking during the lockdown in the UK, there has been a decline in the use of evidence-based support for alcohol reduction and no compensatory uptake of remote supports (telephone support, websites, smartphone applications).

      Jackson SE, Garnett C, Shahab L, Oldham M, Brown J. Association of the Covid-19 lockdown with smoking, drinking, and attempts to quit in England: an analysis of 2019-2020 data. Addiction, 2020. https://doi.org/10.1111/add.15295.

      Limitations

      Strengths of the present study were the use of representative longitudinal data and a widely used and validated measure of problem drinking. Limitations are (1) the reliance on a single cohort (born in 1970) that may affect the generalizability of the study results, (2) the reliance on self-reported data, and (3) the time gap between baseline (2016–2018) and COVID-19 follow-up (May 2020). However, high-risk drinking has been declining in the UK in recent years (e.g., 2006–2016)

      Adult drinking habits in Great Britain. Office for National Statistics.https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/drugusealcoholandsmoking/datasets/adultdrinkinghabits. Updated May 1, 2018. Accessed September 18, 2020.

      and has been shown to be highly stable across the months of the year in the UK.
      • de Vocht F
      • Brown J
      • Beard E
      • et al.
      Temporal patterns of alcohol consumption and attempts to reduce alcohol intake in England.
      This suggests that the size of the change in drinking observed in this study (e.g., doubling of the prevalence of drinking ≥4 times a week) is unlikely to be explained by anticipated year-to-year trends or seasonality effects associated with the gap between baseline and follow-up or the assessment month, respectively. In line with this, there was no evidence that the size of the increase in high-risk drinking was related to the year baseline survey was completed (2016/2017/2018).

      CONCLUSIONS

      In a large sample of middle-aged British adults, the initial period of the COVID-19 crisis and lockdown restrictions was associated with an increase in high-risk drinking patterns and especially frequent drinking. It is important that potential long-term changes in drinking habits are monitored throughout the COVID-19 pandemic.

      ACKNOWLEDGMENTS

      We are grateful to the University College London Centre for Longitudinal Studies for their management of the 1970 British Cohort Study and to the United Kingdom Data Archive for making the data available.
      The Centre for Longitudinal Studies is funded by the United Kingdom Economic and Social Research Council .
      These organizations bear no responsibility for the analysis or interpretation of the data. MD and ER conceived the study, and MD analyzed the data; all authors contributed to the interpretation of the data and drafting and revising the article. Contents of the article have not been presented or published elsewhere.
      No financial disclosures were reported by the authors of this paper.

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