A narrative review of the use of alcohol during the Covid-19 pandemic; effects and implications

Abstract The Covid-19 pandemic created an environment wherein stress and isolation could increase alcohol consumption. The effects of alcohol consumption on Covid-19 susceptibility and the impact of the Covid-19 pandemic on alcohol use, related harms and services were explored. Search terms were inputted to Medline and Embase databases, with relevant published papers written in English chosen. Alcohol ingestion both increased and decreased throughout the population globally, however, the overall trend was an increase. Risk factors for this included female sex, young age, family conflicts, unemployment, mental health disorders, substance misuse and lack of support. Alcohol misuse was found to be an aggravator of domestic violence and worsening mental health. It exacerbated the risk of contracting SARS-CoV-2 and worsened the Covid-19 infection severity, with >10 drinks/week increasing the acute respiratory distress syndrome (ARDS) risk similarly to established risk factors. This was attributed to the immunosuppressive and disinhibition effects of alcohol. Therefore, healthcare professionals should provide support to vulnerable groups, encouraging stress reduction, healthy habits, limiting alcohol consumption (<5 drinks/week) and promoting coping techniques. Self-help tools that monitor individual alcohol intake and psychosocial interventions in a primary care setting can also be employed. Finally, governing bodies should inform the public of the risks of alcohol ingestion during the Covid-19 pandemic. Thus, the Covid-19 pandemic could create a cycle whereby alcohol misuse could become a risk factor for Covid-19 infection and the Covid-19 pandemic could become a risk factor for alcohol misuse. Healthcare professionals should counsel people on alcohol misuse risk and protective factors.


Introduction
On the 11/03/2020 the World Health Organization (WHO) announced the virus Sars-CoV-2 to be responsible for the novel Coronavirus Disease 2019 (Covid- 19) pandemic. 1 This pandemic fundamentally changed behaviors both on an individual and societal level, profoundly affecting physical health, mental health and social norms. In such a context, mental health and substance misuse disorders can rise. Notably, substances, such as alcohol, and opioids, can predispose individuals to a Covid-19 infection, as they are immunosuppressive and can negatively affect lung function. Furthermore, substance misuse can coincide with factors that make social distancing impractical, such as residing in overcrowded spaces, lack of permanent accommodation and disinhibition, increasing the likelihood of contracting SARS-CoV-2. 2,3 Alcohol specifically is a psychoactive substance that can be dangerous both out-with and within the context of the Covid-19 pandemic, with three million deaths globally attributable to its consumption annually. 4 It is commonly ingested, with approximately 2.4 billion people consuming it globally; 1.5 billion male and 0.9 billion female drinkers. 5 Alcohol is correlated with communicable and noncommunicable conditions, as it negatively affects the immune system. In higher doses it has been associated with hepatic damage, gastric and pancreatic inflammation and neurodegenerative conditions, such as dementia. 3 It can also exacerbate violence, risk-taking behaviors, mental health issues and traumas, both for the drinker, such as alcohol poisoning and the people around them, such as intimate partner violence. 4 SARS-CoV-2 is a virus of the Coronavirdae family, which infects the lower respiratory tract. The virus is round with a 31 kb RNA enclosed by a glycoprotein envelope with spike proteins protruding from its surface. A mutation (N501) in the gene that encodes the spike protein, i n c re a s e s v i r a l af f i n it y to hu m an Angiotensin-Converting-Enzyme-2 (ACE-2) receptors. SARS-CoV-2 binds to ACE-2, fuses with the host cell membrane and enters the cell. It induces a primary and then a secondary cytokine storm, corresponding to the activation of the innate adaptive immune system, respectively. Covid-19 resembles a viral pneumonia and can progress through three sequential phases. A dry cough, fever and myalgia are common phase one symptoms. Then, phase two features a worsening of symptoms, as the adaptive immune system, particularly IgG production, reduces viral replication, whilst concomitantly damaging the alveoli. Phase one and two last approximately two weeks, after which the majority of the population recovers. One third of the population however can progress to phase three, involving severe lung inflammation, acute lung injury, acute respiratory distress syndrome (ARDS) and even death. 1 Thus, at the start of the pandemic, WHO called upon governments to consider the risks alcohol imposes to the health of the population and restrict its access during lockdown. 4 Significantly, the Covid-19 pandemic could create an environment whereby alcohol consumption increased, exacerbating both the risk of contracting SARS-CoV-2 and the severity of the Covid-19 infection. This could worsen the pandemic trajectory, propelling people to drink more, creating a vicious cycle.
The primary aims of this review were to establish the impact of alcohol on Covid-19 susceptibility, ascertain changes in alcohol consumption trends globally and assess the correlation between alcohol and associated harms, including domestic violence and mental health. The secondary aims of this review were to determine the impact of the pandemic on alcohol related services and explore options to address problematic drinking during the pandemic.

Methods
This literature review was undertaken from the 2nd of January 2021 until the 20th of March 2021, using a combination of the following search terms: "alcohol," "alcohol consumption," "SARS-CoV-2," "Covid-19, " "immune system, " "domestic violence, " "addiction, " "mental health, " and "telehealth" on the EMBASE and MEDLINE/PubMed databases. Papers were also identified via the reference lists of examined papers. Published papers from 01 January 2019 to 20 March 2021 and papers written in English only were reviewed and chosen according to content relevance. This review complies with the SANRA guidelines. 6

Alcohol use and covid-19 susceptibility
Mucociliary clearance, fundamental in maintaining healthy lungs, is impaired by alcohol consumption. Alcohol damages the epithelial lining of the airways and attenuates the response of airway cilia to external stimuli, 7 increasing infection susceptibility in a dose and exposure dependent manner. 7,8 Additionally, alcohol induces oxidative stress, both by increasing NADPH oxidase, an oxidative stress aggravator, and depleting glutathione, an oxidative stress alleviator. This dysregulates macrophages and damages the antigen presenting process. Alcohol is also associated wit h re duce d g ranu lo c yte mono c yte colony-stimulating factor production, required for the differentiation of circulating monocytes to active alveolar macrophages. This in turn impairs the macrophages' ability to release neutrophil chemoattractants, limiting neutrophil recruitment. 7 Prolonged alcohol exposure can impair not only the innate but also the adaptive immune system. People diagnosed with alcohol use disorder (AUD) suffer from lymphopenia, modifications in T-cell compartments, reduced mitogen-stimulation response and thus cell division, a compromised type IV hypersensitivity response and diminished interferon-gamma production. 7 People who misuse alcohol are more susceptible to viral infections, such as respiratory syncytial virus 7 and severe influenza infection. 9 Additionally, people with AUD are more likely to develop ARDS, with alcohol misuse independently increasing their risk by 2-4 times. 7 Alcohol is also a recognized pneumonia risk factor as it decreases oropharyngeal tone, increasing the likelihood of aspiration. Moderate and heavy alcohol drinkers were 83% more likely to acquire pneumonia, in a dose-dependent manner, 10 with alcoholassociated-liver disease (ALD) patients being even more susceptible to pneumonia due to reduced hepatic clearance and splenic function. 9 Furthermore, chronic alcohol consumption is associated with higher levels of ACE-2. Even moderate alcohol consumption can elevate ACE-2 for 4 weeks post consumption. 5,11 This might be significant as Covid-19 utilizes ACE-2 to enter host cells.
Furthermore, a Danish multi-center cohort clinical trial that recruited 171 Covid-19 positive hospitalized adult patients (not in ICU), explored the alcohol -Covid-19 induced ARDS association. Confounding variables such as age and smoking-status were accounted for. ARDS was reported in 44 (25.7%) participants and severe ARDS in 22 (12.9%). This was significantly associated with higher alcohol consumption, a median of 7 drinks/week for patients that developed ARDS compared to a median of 3 drinks/week for patients that were ARDS-free. Furthermore, alcohol (>10 drinks, 12 g of ethanol/drink per week) was found to increase the risk of ARDS similarly to established risk factors, such as diabetes and immunosuppression. 12

The effect of covid-19 on alcohol consumption
During the Covid-19 lockdown numerous factors worked synergistically to increase alcohol consumption, such as lack of distractions provided by non-alcohol-related activities, for example sports, 13 with alcohol becoming a coping strategy or a form of entertainment for some. 14 Aligned with this, US alcohol sales increased by 55% in the last week of March 2020 compared to the previous year, with a 300% increase in alcohol sales reported by an alcohol E-commerce platform. However, the increase of alcohol consumption at home may have been counterbalanced with the lack of on-premise drinking. 13 Anxiety and panic regarding SARS-CoV-2 generated a hazardous myth, whereby consumption of high-strength alcohol can kill the virus. Needless to say not only that is not the case, 4 but also alcohol increases the risk of infection, both by impairing the immune system and by causing disinhibition and reduced social distancing.
Two theories have been developed regarding alcohol consumption and Covid-19 15 : a. The interplay between economic difficulties, social isolation and personal anxieties increased alcohol consumption. b. The reduced physical availability of alcohol and increased financial burden (loss of employment or additional new alcohol taxes) reduced alcohol use.
Studies that investigated the effect of Covid-19 on alcohol consumption are summarized in Tables  1-3 referring to studies undertaken in Europe, USA/Canada and International/other, respectively, with a simple pooled analysis of consumption trends shown in Figure 1 (Appendix 1). Both aforementioned theories were observed with trends of increasing and decreasing alcohol consumption reported. Nonetheless, the predominant trend was a rise in alcohol consumption in approximately 20% of the population. Risk factors for this were excess worry, stress, loneliness, poor mental health, lack of organization, boredom, remote working, female sex, young age, living in a big city and having children at home.
Specifically, most US/Canadian studies reported an increase in alcohol consumption during lockdown, 15,16,18,19 by approximately 20%, 15,16,18 with two studies 15,16 highlighting that younger people were more prone to hazardous drinking. However, the one study 17 that reported a decrease in both alcohol consumption and binge drinking also reported that the individuals who continued drinking alcohol were consuming larger quantities (Table 1).
A Chinese study 21 showed an overall increase in alcohol consumption, including relapses for people who were abstinent before lockdown. Similarly, an Australian study 22 reported that 1 in 5 study participants increased their alcohol consumption, contrasting with the findings of an international study 20 that identified an overall reduction in binge drinking ( Table 2).
European studies (Table 3), highlighted an increase in alcohol consumption in 15%-30% of the surveyed participants. [23][24][25][26][27] One Polish study 25 reported a rise in alcohol consumption in 18% of the participants, however 40% of participants reported a decrease, so the overall trend for this study was a reduction in alcohol consumption.

Special considerations; AUD and ALD
The Covid-19 pandemic created a challenging environment for people with AUD, who were unable to connect with support networks, increasing their risk of relapse. 13 This was exacerbated by an increase in relapse risk factors, such as depression, fear, anxiety and isolation. 28 An Austrian retrospective study recruited 127 people with AUD who were either abstinent from alcohol (n = 37), relapsed (n = 41) or still consuming alcohol (n = 49). Alcohol consumption was quantified using the Alcohol use disorders identification test for consumption (AUDIT-C), with relapsed and alcohol consuming groups consuming hazardous quantities of alcohol (AUDIT-C 11 and 10, respectively). Additionally, 10 participants (7.9%) were at risk of developing Covid-19 related post-traumatic stress disorder (PTSD). 28 Furthermore, liver disease is one of the comorbidities increasing vulnerability to Covid-19 9 .

Covid-19, alcohol bans and withdrawal
Globally, during the Covid-19 pandemic, governments implemented numerous alcohol regulations. Canada, New Zealand, the US, the UK and Australia announced outlets for selling alcohol for off-premise consumption as essential services. 15,29 Other countries, such as India, South Africa and Thailand, altogether banned alcohol in an attempt to promote self-isolation, compliance with social distancing and limit domestic violence. 30,31 This was by no means a panacea; it was associated with alcohol withdrawal, suicides 30 and the perils associated with illegal alcohol procurement, including adulterated or surrogated alcoholic drinks (e.g. poisonous fungus, methanol toxicity). 32 Specifically, a study in India recruited 96 male patients with a mean age of 43 years old, hospitalized with severe alcohol withdrawal syndrome (AWS), after the alcohol ban was implemented.
All patients were heavy alcohol drinkers (mean = 18 Units/day) and 73 of the 96 patients were living below the poverty line. 77 of these patients presented with delirium tremens (DT), 16 with withdrawal seizures and 12 with withdrawal hallucinations. A statistically significant doubling of patients with AWS was demonstrated, from 4 cases/day before the alcohol ban to 8 cases/day after the ban. 33

Covid-19, alcohol at home and domestic violence
Reports indicate an increase in domestic violence during the Covid-19 pandemic, 34,35 with a rise in calls to child support lines and requirement for police attendance at domestic violence episodes reported. 36 Alcohol can increase the risk of the drinker becoming a perpetrator and increase the severity of the misuse, 37-39 as perpetrators are violent and abusive regardless of alcohol consumption, 40 but without alcohol, abuse might take the form of intimidation, coercion or control. 41 Furthermore, there is a higher probability for an individual to be a victim of abuse if one or both of the relationship partners consumes alcohol. 41 Victims might also drink before or after the abuse, as a coping or anticipatory strategy, respectively. 41 Additionally, the perpetrator can use alcohol as a form of control, if the victim is addicted to it. 41 High alcohol consumption at home can also impact children's perception of alcohol. It can "normalise" hazardous levels of alcohol consumption and promote connotations where alcohol becomes an essential coping strategy. 29,42 Thus, alcohol consumption at home can harm both the drinker and household members.

Covid-19 and mental health
Substance misuse, including alcohol, has been related, both during the Covid-19 pandemic and in general, with extreme worry, personal socioeconomic uncertainties, xenophobic attitudes, PTSD symptoms and compulsive checking. 15 It is commonly believed that alcohol reduces stress, when in fact, it is a risk factor for this, whilst also exacerbating preexisting mental health disorders. 43 This association is most prominent in people with depression, psychosis or anxiety, with some using alcohol to self-medicate. 44 Alcohol misuse has also been associated with suicidal behaviour. 45 Aggravating factors for alcohol misuse have surfaced during the Covid-19 lockdown, such as family conflicts, financial struggles, and unemployment. The rise in alcohol intake in turn increases feelings of impulsivity, hopelessness, loneliness and aggressiveness, all of which are risk factors for suicide. 46 A Chinese online survey that recruited 1074 people identified that 32.1% of the participants reported lower mental well-being, 29% anxiety and 37.1% depression associated with isolation during lockdown. Furthermore, dangerous levels of alcohol consumption were reported in 29.1% and damaging levels in 9.5% of the participants, with alcohol addiction reported in 1.6%. People aged 21-30 years old were more vulnerable to worse mental health and hazardous drinking. Interestingly, there was a small increase in people suffering with alcohol addiction compared to the substantial increase in dangerous and damaging drinking. 47 However, behaviors like addiction take time to develop and the complete picture of alcohol addiction due to Covid-19 might not have emerged yet.
Similarly to alcohol, Covid-19 has also been recognized as a creator and aggravator of mental health problems, with two syndromes established; the Covid Stress Syndrome and the Covid Disregard Syndrome. Specifically, Covid Stress syndrome symptoms include Covid-19 associated PTSD and having concerns about touching Covid-19 contaminated objects, about the socioeconomic implications of Covid-19 and about foreigners spreading Covid-19. In contrast, Covid Disregard syndrome symptoms include indifference for social distancing and confidence that Covid-19 is not a threat. 15 Due to the association of mental health disorders with alcohol misuse, 44,46 these Covid-19 induced syndromes could contribute to a rise in alcohol consumption.

Alcohol services
During the Covid-19 pandemic many outpatient clinics were canceled or patients were unable to attend, due to difficulties in transport or fear of being in a hospital. 13 This has been challenging, as a substantial fraction of substance misuse therapies involve group-based therapy and peer support groups. These services adapted to the new restrictions, for example by reducing the number of participants per group and halting provision of therapeutic leaves. To avoid discharging patients with minimal support, additional group-based therapies in an outpatient context were implemented. However, outpatient face-toface consultations transitioned into telephone consultations, which did not provide an equal level of support. 48 Some centers, however, used the Covid-19 pandemic as an opportunity to review practices, with one center updating their thiamin administration protocols to minimize patient transport between hospitals. Additionally, to reduce patient-nursing staff encounters, patients became more autonomous with handling their medication. 48 In Kerala, India, where an alcohol ban was imposed, a more controversial approach was adopted in revising alcohol services, whereby doctors prescribed alcohol to people with alcohol addiction, to reduce the number of associated suicides. 31

Addressing problematic drinking and patient counseling
There is an established association between stress and alcohol consumption. 49 Strategies to promote healthy living and reduce stress in an attempt to reduce alcohol use can be promoted, such as healthy sleep habits, limiting alcohol consumption (<5 drinks/week), improving family relationships and encouraging exercise and art. 19 Services can be provided to vulnerable groups at risk of alcohol misuse, including self-help tools that monitor individual alcohol intake, regular mental health screening tools 46 and counseling in a primary care setting. 50 Specifically, dialectic behavioral therapy (DBT), a psychosocial intervention that is based on the combined principles of behavioral and cognitive restructuring and acceptance strategies, may improve alcohol-related outcomes, namely promote abstinence and reduce alcohol consumption. When DBT was delivered online, outcomes remained favourable. 51 Likewise, cognitive behavioral therapy, a psychosocial intervention that aims to alter negative thinking and behaviors, improve emotional control and encourage use of coping techniques, may reduce alcohol consumption in adolescents. 51 Brief interventions that have been shown to reduce alcohol consumption can also be employed. 50 These are based on providing: (1) feedback on the patient's alcohol intake and quantifying safe alcohol limits, (2) information on alcohol related harms, (3) information on the advantages of decreasing alcohol intake, (4) tailored advice, (5) coping strategies and (6) a personalized alcohol reduction plan. 50 Furthermore, at a local and national level, governing bodies should monitor alcohol consumption and inform the public of the additional risks of alcohol consumption during the Covid-19 pandemic. 46 Telehealth can be employed to provide counseling, support and reassurance. 49,52,53 Moreover, digital interventions have been successful in the context of problematic drinking and have been shown to reduce alcohol consumption by 3 UK standard drink units (23 g) per week, whilst having no difference in effectiveness compared to face-to-face interventions. 54 In the context of the Covid-19 pandemic, they enable healthcare providers to safely stay in contact with patients, allowing for unrestricted diagnosis, treatment and follow-ups via interviewing. It might also be a more accessible option for a subgroup of patients, who would not feel comfortable to attend substance misuse clinics, due to fear of being stigmatised. 46,55 Frequent telehealth appointments might be needed for high-risk patients and proactive follow-up appointments for previously stable and abstinent patients. 13 When face-to-face appointments are necessary, screening questionnaires can be used prior, to assess whether a patient has Covid-19 symptoms. 48 Crucially, older adults and people with limited access to the internet must not be marginalized and ignored. Unfamiliarity with technology should not be allowed to contribute to healthcare inequalities. These considerations apply to practitioners too, who should be trained adequately to provide an equivalent standard of care as face-to-face consultations. Finally, organizations should be willing to invest in technology that will make telehealth feasible, whilst protecting patient confidentiality. Treatment options and relevant protocols should be adapted to allow for standardization of service provision via tele-health to allow care to be provided with equity, regardless of age and socioeconomic status. 56

Discussion
This review has several limitations. Firstly, most studies that comprised the primary analysis of this narrative review were online surveys, limiting the sample pool to participants with internet access and necessary literacy skills, introducing potential selection bias. Additionally, a limited number of databases were searched and a restricted number of eligible studies available, due to the novel nature of the topic. Furthermore, the term "domestic violence" was utilized as a search term rather than the thread "intimate partner violence" OR "domestic violence," possibly omitting relevant studies. A further limitation of this study was the absence of confounding factor analysis, due to the lack of reporting in the primary literature.
Overall, alcohol negatively impacts mental and physical health, regardless of the Covid-19 pandemic. The pandemic itself has also affected the physical and mental well-being of people throughout the globe. However, the synergistic effect of the two has had by far the worst effect. Alcohol misuse exacerbates both the risk of contracting SARS-CoV-2 and the Covid-19 infection severity, with >10 drinks/week found to increase the risk of ARDS similarly to established risk factors. This is likely due to the immunosuppressive and disinhibition effects of alcohol. Furthermore, the Covid-19 pandemic has brought to light risk factors associated with increased alcohol consumption, namely stress, boredom, female sex, young age, having children at home, family conflicts, unemployment, preexisting mental health disorders and substance misuse. Importantly, both an increase and decrease of alcohol consumption was observed globally, with a variety of trends reported (Tables 1-3).
Thus, the Covid-19 pandemic could create a vicious cycle (Appendix 2, Figure 2) for people who increased their alcohol use, whereby alcohol misuse could become a risk factor for Covid-19 infection and the Covid-19 pandemic could become a risk factor for alcohol misuse. Therefore, now it is more important than ever for healthcare professionals in a community setting to reach out to patients and provide tailored support focused on stress reduction, healthy habits and coping techniques to counterbalance the alcohol misuse associated risk factors.