Alcohol use in self-isolation during the COVID-19 pandemic: a cross-sectional survey in Brazil

Abstract Objectives To assess alcohol use and perceived change in alcohol consumption (before and during the pandemic) in Brazilians during the COVID-19 pandemic, their correlates, and their associations with depressive, anxiety and co-occurring depressive and anxiety symptoms (D&A). Methods This is a cross-sectional study comprising 992 individuals in self-isolation. A self-report questionnaire was used to assess whether participants were drinking during self-isolation and whether they changed their drinking behavior (drinking less, more, or no change) from before to during the pandemic. D&A symptoms were assessed using the Beck Depression and Anxiety Inventories (BDI and BAI). Results A total of 68.5% of participants reported alcohol consumption during the pandemic, and 22.7% of these reported increased alcohol use. Smoking was positively associated with alcohol consumption during the pandemic. Alcohol consumption was associated with anxiety (OR = 1.40, 95%CI 1.06-1.85, p < 0.01) and D&A (OR = 1.38, 95%CI 1.02-1.87, p = 0.033) symptoms. Conclusions Drinking during self-isolation was prevalent and was associated with risk factors for alcohol use disorders. The long-term effects of high drinking rates and increased consumption should be proactively monitored and assessed.


Introduction
The COVID-19 pandemic has caused an unprecedented global health crisis with consequences stemming not only from the morbidity and mortality of the virus, but also from prevention strategies. 1 Social distancing measures have been implemented worldwide to reduce infection transmission, generating considerable disruption in people's routines and psychological well-being. 2 In this scenario, changes in alcohol consumption are expected and may have consequences for pandemic management and the population's mental health. 3 Studies from previous global crises showed no changes in alcohol use in the overall population. 4,5 Notwithstanding, this appearance of stability occurred at the expense of decreased use among some populations while more vulnerable subgroups increased their use of alcohol. 4 Therefore, changes were observed in the demographic profile of problem drinkers. Additionally, countries can be affected differently. After the 2008 Great Recession, problem drinking increased significantly more among less educated men in the US, whereas in Spain highly educated women were more affected. 4,6 Overall, anxiety and depressive symptoms mediated drinking behavior. 4 So far, studies conducted during the COVID-19 pandemic have shown both increases and decreases in alcohol use, which can vary according to environmental, societal, and individual factors, including psychological distress. 4,[7][8][9] Environmental and societal factors, such as lack of social events and absence of peer pressure to drink have been associated with decreased use, 10,11 whereas increased use has been associated with some individual factors, such as stress and loneliness. [7][8][9][10][11][12][13] Additionally, higher age, higher income, and unemployment have also been associated with increased drinking. 9,13 A study conducted by The Pan-American Health Organization (PAHO) identified a reduction in heavy drinking, except among individuals with anxiety symptoms, in which this behavior increased. 14 However, their results comprised all countries from Latin America and the Caribbean and, except for an early descriptive data analysis, 12 little is known about the Brazilian population's drinking behavior during self-isolation. Therefore, our aims were to:1) assess alcohol use and changes during self-isolation in Brazil; 2) assess the demographic correlates of alcohol use and changes in use; and 3) assess the associations between alcohol use and changes and depressive, anxiety, and co-occurring depressive and anxiety symptoms. We hypothesize that drinking behavior would be associated with socioeconomic status, sex, age, clinical or psychiatric morbidity, and psychiatric symptoms.

Recruiting and inclusion criteria
The study data are derived from an online survey and the methods used have been described elsewhere. 15 Individuals (≥ 18 years) living in Brazil and in selfisolation (staying at home and leaving home for essential activities only, such as buying food or medicine or visiting a physician) due to the COVID-19 pandemic, who agreed to participate in the survey were eligible. In Brazil, social distancing measures started in March 2020 and were heterogenous across states and cities and the decision to self-isolate was voluntary. Data was collected between April 5th and May 11th, 2020.

Alcohol consumption use and increase during the pandemic (outcome)
Alcohol consumption was assessed with two questions: "Do you drink alcoholic beverages?'' and, "Now that you are in self-isolation, do you consider that: you are drinking more, drinking less, or drinking the same amount?"

Demographic correlates
Demographic data were collected, as well as days in self-isolation, current smoking, and self-reported previous diagnosis of chronic physical diseases and psychiatric disorders.

Statistical analysis
Descriptive data for continuous variables were expressed as mean (standard deviation) or median and interquartile range (IQR). Categorical variables were expressed as absolute frequencies (%). Logistic regression models were used to evaluate the correlates of alcohol consumption, increase in alcohol consumption (before and during the self-isolation period), and the associations between alcohol consumption (yes vs. no) or increase in alcohol use (using "drinking the same amount" plus "drinking less" as the reference group) and symptoms of depression, anxiety, or D&A. The models tested were adjusted for age, sex, ethnicity, marital status, employment, family income, and number of household inhabitants. Results from the logistic regression models were presented as odds ratios (ORs). Statistical significance was set at p < 0.05. The statistical analysis was performed with SPSS version 22.0 (IBM Corporation).

Ethical considerations
The study was approved by the Federal University

Results
Demographic data and other descriptive analyses are detailed in Table 1. negatively associated with alcohol consumption during self-isolation (see Table 2).

Changes in alcohol consumption in self-isolation
(before and during) and correlates  Table 3). A household income in logistic regression models. We found no association between psychiatric symptoms and drinking more (Table 4). Odds of those who reported consuming more alcohol consumption versus those who reported less consumption or no change in alcohol consumption (reference).

Discussion
We found that 68.5% of our participants reported drinking during the pandemic and that 22.7% of those who did so reported increased drinking while 32.5% Caribbean countries. 14 Their pre-pandemic prevalence of drinkers and binge drinking were also similar to those found in Brazil. More specifically, the prevalence of alcohol drinkers in Brazil was 66.4%, 38.4% of whom reported binge drinking. 18 Additionally, 20% of binge drinkers consume 56% of all the country's alcoholic beverages. 19 The distribution of drinkers between age groups and sex in our sample was also similar to that found in a national survey, except that we found a higher prevalence among women (59% vs. 67%). 18 Considering that the alcohol consumption profile of The COVID-19 pandemic has brought financial insecurity and, consequently, a great psychological burden, especially to the working-age population.
Previous studies of economic crises and alcohol use have shown that people with lower income reduce their drinking due to loss of resources, whereas the opposite occurs among those with higher incomes, in which the economic factor may be overlaid by drinking as a coping strategy. 21 In fact, higher income was associated with heavy drinking episodes during the pandemic in the PAHO study. 14 However, we found that middle, but Additionally, our middle-class sample was comprised predominantly of young adults. They may have a lower risk of drinking due to parenting responsibilities, starting a working career, or because they prefer to drink in social settings. Nevertheless, we did not find an association between young adulthood and drinking before or during self-isolation.
Notably, anxiety and co-occurring D&A symptoms were associated with drinking even after controlling for other covariates. These psychiatric comorbidities have been associated with higher risk for alcohol use disorders (AUD), faster progression of AUD, and  27 Anyhow, because increases in anxiety and depressive symptoms have been associated with the current pandemic, 2,28 careful assessment of alcohol use among individuals with these symptoms is imperative.
We found no association between psychiatric symptoms and increased alcohol use. One possible explanation is that individuals with anxiety and D&A symptoms already had high levels of alcohol use before the pandemic.
Not surprisingly, we found that smoking was associated with both alcohol use and increased use. The combination of nicotine and alcohol is highly comorbid and is associated with cross-reinforcement in the reward system as well as with cross-tolerance, enhancing the risk of hazardous drinking. 23,29 Our study has some limitations. First, because we used secondary data from another study, 15 we did not use validated scales for AUD. Also, alcohol consumption or even increasing alcohol consumption does not per se mean hazardous drinking. However, our findings of drinking being associated with known risk factors for AUD is worrying and should encourage further investigation. Moreover, we found that those individuals who had been drinking were more likely to present anxiety and co-occurring D&A, which indicates a need to target individuals with psychiatric symptoms. Another limitation is that the study sample is not representative of the Brazilian population.
Women were overrepresented and most participants were from the South and Southeast regions of Brazil.
Additionally, low-income populations and smokers were underrepresented. Finally, this is a cross-sectional study and causal relationships cannot be inferred, and memory bias might play a role.
In conclusion, drinking during self-isolation was prevalent, varied across demographic subgroups, and was associated with higher risk of smoking and anxiety and D&A symptoms. The long-term effects of increased consumption can have implications for public health. Therefore, it should be monitored and assessed, since both smoking and psychiatric symptoms were associated with AUD.