Covid-19 and alcohol—a dangerous cocktailBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1987 (Published 20 May 2020) Cite this as: BMJ 2020;369:m1987
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One area of substance misuse treatment that has suffered from the Covid epidemic is in inpatient detoxification provision. People with chronic alcohol dependence are often in poor health e.g. from liver disease and are at significant risk from Covid so the need for inpatient detox provision is great. However, many detox units have closed in recent years due funding cuts. There are only 5 NHS detiox units are left in England. Due to covid many of those remaining are shut due to staffing gaps or being treated as non essential elective services. Although detox units have an important role in supporting acute hospitals and getting patients effective alcohol treatment, no NHS detox unit is open in Northern Ireland. There is only one NHS detox unit serving the whole of southern england.
Competing interests: No competing interests
Your "No competing interests" pub operator correspondent (BMJ 2020;369:m1987) makes a fair point about your lack of impartiality regarding the sales figures for alcohol. The null hypothesis approach to the 67% increase in sales would be that this represents the amount of alcohol normally consumed in pubs and restaurants, leaving total alcohol consumption unchanged
Competing interests: No competing interests
Finlay and Gilmore rightly draw attention to two vulnerable groups of drinkers during the Covid-19 lockdown. In addition, and of central importance, is that whether parents drink more or less during Covid-19 lockdown, their children are far more likely to see them drink simply because they are all at home, off school and off work, for an extensive period of time. This is happening at a time where there is substantial evidence of the intergenerational transmission of alcohol habits and alcohol misuse through parental role modelling.
Alcohol expectancies refer to children’s beliefs regarding positive or negative effects of alcohol and are predictors of their drinking behaviours. Research involving young adults has established that positive alcohol expectancies are associated with greater alcohol use as well as concurrent and future hazardous alcohol use. With regard to lock down, it is important to point out that the association between parental drinking behaviour and children’s alcohol expectancies develops within a short period of time.
Exposure to parental drinking has been associated with pre-teens’ lifetime alcohol use. Recent prospective studies, adjusting for socio-demographic characteristics and family factors, find that hazardous parental drinking predicts mid-adolescent hazardous drinking. Parental alcohol use during adolescence has recently been found to be directly related to adolescents’ heavy drinking. And looking further ahead, there is further evidence of a direct pathway from parental alcohol use to alcohol use in young adulthood. Children whose parents misuse alcohol have increased risks of alcohol misuse in adulthood. Given the current concern over children’s mental health, there are new concerns that the research focus on children of parents with alcohol use disorders has eclipsed the potentially wider-reaching effects of subclinical parental drinking on the development of depression and anxiety in children.
While interest in pathways to future drinking continues to focus on social influences and cultural norms including social media, factors considered to exist outside the home, there has been an elephant firmly ensconced in the room. Many studies of adolescent drinking have failed to include parental drinking even as a confounding variable in the analyses, let alone as a major explanatory factor. It’s time that Britain asked itself why such conspicuousness by absence? For if we fail to answer this, we will fulfil Finlay and Gilmore’s prophecy of ‘the toll of increased alcohol harm for a generation’.
As a PSHE health education lecturer to children and parents, it’s become clear to me that parents feel uncomfortable with the suggestion that their alcohol consumption may influence their children’s alcohol consumption, both now and for decades to come. Interestingly, they are quite willing to accept that their example and role modelling in other health behaviours may well have long term influences on their children, but for them alcohol seems to merit an entirely different consideration.
Many parents believe that it is important to drink naturally in front of their children but to drink responsibly. And despite the fact that the World Health Organisation, concurring with many others, has stated ‘delaying the age at which young people take their first drink lowers their risk of becoming problem drinkers later in life’, many continue to revere what they believe is the French approach to introducing their children to responsible drinking.[10; 11] Their rationale is that to prevent alcohol problems, it is necessary to provide modest amounts of alcohol during early adolescence and even late childhood so that children “get used” to handling it, because it is a social learning process. However, when I offer to protect their children from cocaine addiction by giving them lessons in sensible snorting, they laugh. I’ve lived in France and have also lectured at French schools in the UK and in France and it may surprise many Britons that many French parents and doctors have developed great reservations regarding the wisdom of their former approach to child drinking and the subsequent very high levels of alcohol-related mortality and liver disease.
Over the past three decades, I’ve travelled abroad extensively, often volunteer teaching, to observe child health and development in more obscure cultures, including North Korea, Bolivia, Turkmenistan, Burkina Faso, Bhutan and many others. Although not an empirical evaluation, these observations have provided an oblique second opinion, a reality check on our assumptions about the norms and influences in our culture. One recurring theme is that, generally, in societies where parents and culture disapprove of children drinking, children are less likely to drink, and in cultures that frown upon drunkenness, children are less likely to get drunk.
Returning to Britain during lockdown, the front cover of The Times magazine features the headline ‘Binge drinking… darling, how many units?’ and is followed on the article inside with the title “Well, you don’t have to be sober to work from home’. A famous journalist couple with children write entertainingly about the ups and downs of heavy drinking at home during lockdown. These sentiments occur in a culture where it is often easier to bring one’s child to the local pub than to the local health club and where the legal drinking age at home remains at five years of age, where MPs often vote when they are drunk on alcohol they consumed in the subsidised House of Commons bars and that they are more likely to binge-drink than the rest of the population, where alcohol charities and lobby groups have preferred to focus on improving resources and treatments for alcohol use disorders but noticeably refrained from drawing attention to prevention beginning in childhood and in particular the role of parents in that prevention. As an American, I know many of my fellow countrymen prefer not to consider the role of gun ownership in causing significant health problems - shooting fatalities - and I sense some analogy when it comes to Britain standing back from the bottle and considering children, parental drinking and next generation alcohol problems.
Covid-19 and alcohol may indeed prove to be a dangerous cocktail in more ways than we realise if monkey see, monkey do.
01. Finlay I, Gilmore I. Covid-19 and alcohol—a dangerous cocktail BMJ 2020; 369 :m1987
02. Grazioli VS, Lewis MA, Garberson LA, Fossos-Wong N, Lee CM, Larimer ME. Alcohol expectancies and alcohol outcomes: Effects of the use of protective behavioral strategies. J Stud Alcohol Drugs. 2015 May;76(3):452-8.
03. Smit K, Voogt C, Otten R, Kleinjan M, Kuntsche E. Alcohol expectancies change in early to middle adolescence as a function of the exposure to parental alcohol use. Drug Alcohol Depend. 2020 Mar 25:107938.
04. Smit K, Otten R, Voogt C, Kleinjan M, Engels R, Kuntsche E. Exposure to drinking mediates the association between parental alcohol use and preteen alcohol use. Addict Behav. 2018 Dec 1;87:244-50.
05. Sharmin S, Kypri K, Wadolowski M, et al. Parent hazardous drinking and their children’s alcohol use in early and mid-adolescence: prospective cohort study. Eur J Public Health. 2019 Aug 1;29(4):736-40.
06. Parra GR, Patwardhan I, Mason WA, et al. Parental Alcohol Use and the Alcohol Misuse of their Offspring in a Finnish Birth Cohort: Investigation of Developmental Timing. J Youth Adolesc. 2020 May 6.
07. Lund IO, Skurtveit S, Handal M, et al. BMC Public Health. Association of Constellations of Parental Risk With Children’s Subsequent Anxiety and Depression: Findings From a HUNT Survey and Health Registry Study. JAMA Pediatr. 2019 Mar 1;173(3):251-9.
08. MacArthur GJ, Hickman M, Campbell R. Qualitative exploration of the intersection between social in uences and cultural norms in relation to the development of alcohol use behaviour during adolescence. BMJ Open 2020;10:e030556. doi:10.1136/ bmjopen-2019-030556
09. Donovan JE. Commentary on Rossow et al.(2015): Early Days Yet in the Cycle from Peer to Parent Drinking as Influences on Adolescent Alcohol Involvement. Addiction (Abingdon, England). 2016 Feb;111(2):218.
10. World Health Organisation. Adolescents drink less, although levels of alcohol consumption are still dangerously high [press release]. (2018 September 26) [cited 2020 May 24]. Available from:
11. Clare PJ, Dobbins T, Bruno R, et al. The overall effect of parental supply of alcohol across adolescence on alcohol‐related harms in early adulthood—a prospective cohort study. Addiction. 2020 Feb 7.
12. Costa M, Barré T, Coste M, et al. Screening and care for alcohol use disorder in France: expectations, barriers and levers using a mixed-methods approach. BMC Public Health. 2020 Dec;20(1):1-5.
13. Coren E, Coren G. Binge-drinking, us? Well you don’t have to be sober to work from home. The Times Magazine. 2020 May 9:58-59.
14. Rao R, Bakolis I, Das-Munshi J, et al. Alcohol consumption of UK members of parliament: cross-sectional survey. BMJ Open 2020;10:e034929. doi:10.1136/ bmjopen-2019-034929
Competing interests: As a health education lecturer, preventing alcohol use disorders in children is one of the many topics I address and I receive payment for this work.
The contents of your Cocktail did not include the inevitable surge in births of infants with the neurodevelopment impairments of Fetal Alcohol Spectrum Disorder: an appalling omission.
Indeed, the items of your Cocktail are often a direct result of prenatal alcohol exposure.
The consequences of prenatal alcohol exposure [ and I would include paternal preconceptual alcohol consumption] will impact society long after Covid_19 has joined other pandemics in our remote collective memory.
Competing interests: No competing interests
Your editorial seems to highlight only one side of a story, which has managed to grab headlines. Everyone loves to read about impending doom it seems.
Firstly, I applaud your motivation to highlight the absolute necessity to shore up support for alcohol dependents and their families which has no doubt waned during this pandemic. I also believe that those suffering domestic abuse should now, more than ever, have access to the support they need.
I am however crushingly disappointed at the binary nature of your outlook. A lot of worrying statistics but only taken from the worrying statistics pile.
Yes, a 22% increase in alcohol sales in supermarkets (is this year on year sales?) in the run up to lock down is a concern, but this isn't counter balanced with a drop off in alcohol sales in the on trade throughout March of 40% and now as we know 100%.
I wonder what the increase in toilet paper sales was in the same period? Does this mean we're all going to the toilet more?
The domestic violence figures are concerning, but so far only quoted from police data from 2004 - 2012?
There is no making light of domestic violence and crimes committed in the home, often fuelled by alcohol. There is however an argument that 'bad people' may move their behaviours from the high street to the home as I imagine, but don't know, that reports of street violence and crime outside the home have dropped off significantly since the outbreak of the pandemic.
A much more recent survey during the pandemic of whether people are drinking more at home (2000 adults) showed that 24% of adults felt they were drinking more than before while 17% felt they were drinking less. So an uptick in drinking of 7%. Hardly a tsunami of public health concern and I would say pretty understandable given the circumstances in the last 8 weeks.
My point is that alcohol, health and behaviour are all interlinked as you have illustrated, but that there it is a much more complex social issue than illustrated. There is always a case for counter balance in all of the scenarios illustrated. It worries me that the commissioned report will harbour information from those who have suffered in the most extreme ways only and therefore will be biased and unbalanced.
I salute your intention to raise awareness for the help needed by those suffering from alcohol related issues, I just feel that with a more balanced approach there may be a more balanced outcome which would be a more successful way of influencing people's behaviour.
Competing interests: No competing interests