|Year : 2023 | Volume
| Issue : 1 | Page : 130-136
Does a ban on liquor sales benefit alcohol dependence patients? A study on usage and procurement of alcohol during the COVID-19 lockdown
Naren Albert Rajendran, Kailash Sureshkumar, Shabeeba Z Kailash, Sivabackiya Chitravelu, Niha R Rumaisa
Department of Psychiatry, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Tamil Nadu, India
|Date of Submission||07-Jul-2022|
|Date of Acceptance||27-Aug-2022|
|Date of Web Publication||21-Jan-2023|
Dr. Kailash Sureshkumar
Department of Psychiatry, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Chengalpattu, Tamil Nadu
Source of Support: None, Conflict of Interest: None
BACKGROUND: Restricting the availability of alcohol in “dry states” and during the COVID-19 lockdown reveal illegal trading and consumption of illicit liquor leading to deaths and use of alternate harmful substances. The current study aims to fill the gaps in the literature to study alcohol usage and its procurement during its complete ban of sale.
MATERIALS AND METHODS: A cross-sectional study of purposively sampled alcohol-dependent patients (n = 62) was conducted in an OPD setting, comparing two time periods: before and during total lockdown 2020. After reinforcing confidentiality and privacy, data were collected and analyzed.
RESULTS: Alcohol usage during the lockdown was positively related to severity of alcohol dependence syndrome (r = 0.67, P = 0.00), quantity of alcohol consumed (r = 0.59, P = 0.00), and its cost of procurement (r = 0.43, P = 0.00) before lockdown. During the lockdown, the proportion of consuming alcohol more than or equal to 90 units weekly significantly decreased (Pearson Chi-square = 4.12, P = 0.04) and their predicting factors are rural residential location, moderate-income bracket, low socioeconomic class, and severe alcohol dependence. Furthermore, a significant increase in the proportion of procuring alcohol from the black market or used illicit liquor was observed (Fisher's exact test P = 0.00) with higher odds being associated with illegal procurement before lockdown (odds ratio = 22.00; 95% confidence interval = 3.93–123.28; P = 0.00). Increased use of alternate substances such as nicotine (37.1%) and cannabis (9.7%) during the lockdown was also observed.
CONCLUSION: Although alcohol consumed did not significantly differ, illegal sources and money spent on procurement increased during the lockdown. Thus, a legal ban of liquor sales did not benefit alcohol dependence patients, and such restriction availability strategies may benefit from health awareness, treatment, and psychosocial support.
Keywords: Alcohol, alcohol dependence syndrome, ban, COVID-19
|How to cite this article:|
Rajendran NA, Sureshkumar K, Kailash SZ, Chitravelu S, Rumaisa NR. Does a ban on liquor sales benefit alcohol dependence patients? A study on usage and procurement of alcohol during the COVID-19 lockdown. Indian J Health Sci Biomed Res 2023;16:130-6
|How to cite this URL:|
Rajendran NA, Sureshkumar K, Kailash SZ, Chitravelu S, Rumaisa NR. Does a ban on liquor sales benefit alcohol dependence patients? A study on usage and procurement of alcohol during the COVID-19 lockdown. Indian J Health Sci Biomed Res [serial online] 2023 [cited 2023 Jan 28];16:130-6. Available from: https://www.ijournalhs.org/text.asp?2023/16/1/130/368327
| Introduction|| |
Globally, alcohol has been substantially linked to mortality, disease burden, and social harm. The burden attributed to the use of alcohol included physical fights after drinking, drinking during the day, drunk driving accidents, psychiatric emergencies, risk of suicide, spousal abuse, wages lost, personality disorders, and risk-taking behavior., One of the environmental determinants of alcohol-related harm was found to be availability: defined as the convenience or ease of obtaining alcohol. “Distribution of consumption model” also hypothesized that an increase in the availability of alcohol produced an increase in the aggregate level of alcohol consumption which, in turn, increased the level of alcohol-related damage. Previous three international WHO projects showed an increase in drinking-related damage due to an increase in alcohol sales, as well as a study on a 50-year trend in 14 European countries and Canada revealed a strong association between alcohol sales and mortality from alcohol-specific causes, trauma, chronic disease, and total mortality. An Australian study on residential access to alcohol outlets also revealed similar results, with residents having greater access to liquor stores being more likely to consume alcohol at harmful levels and having hospital contact for anxiety, stress, and depression.
From systemic reviews and meta-analyses, effective policies in reducing alcohol-related harm were found to be regulating the price and availability of alcohol. It also showed that policies restricting alcohol trading times led to a decreased risk of injuries, alcohol-related hospitalizations, and homicides but a less compelling impact on assault and motor vehicle crashes. A study on Indian policies revealed that taxation and minimum legal drinking age have been effective in reducing alcohol consumption, fatalities from motor vehicle accidents, and crimes against women. However, studies also revealed that in middle- and low-income countries, such measures are less effective due to difficulties in its implementation, enforcement, and unlicensed sale of liquor. Furthermore, studies on Indian “dry states” had revealed an increase in brewing, trading of illicit liquor, abuse of alternate illegal substances, and deaths due to methanol poisoning after a complete ban of liquor and whenever a complete ban was imposed in Tamil Nadu, deaths due to methanol consumption and illegal sales of illicit liquor such as toddy and arrack were found to be increased.
To mitigate the effects of the COVID-19 pandemic, governments worldwide announced a lockdown. Some countries limit the location or timing of the availability of alcohol. In USA and UK, physical distancing restrictions showed increased alcohol sales from supermarkets and online platforms. In contrast, other countries, including India, announced a complete ban on liquor sales, due to which there were reports of suicides, an increase in hospital contact of people with alcohol withdrawal, deaths due to consumption of toxic alcohol, black marketing, and illicit brewing of liquor during the lockdown. Thus, with several previous studies being found to focus on the burden of alcohol when restrictions are imposed, there is a lack of literature to describe alcohol usage and procurement during its complete ban of sale. Our study focused on the amount of alcohol usage and its sources of procurement in patients with alcohol dependence syndrome during the COVID-19 lockdown (March 24, 2020–May 6, 2020) and compared it to a period before the lockdown.
| Materials and Methods|| |
The current study was done in a tertiary care setting between July 2020 to August 2020, using a cross-sectional, nonblind study design, and a total of 62 cases were selected. The protocol for the study was approved by the Institutional Human Ethics Committee Chettinad Academy of Research and Education, Kelambakkam, Proposal No. 180/IHEC/November 2020 dated 27.11.2020. Convenience sampling technique was followed, and cases were patients aged 18–59 years, attending the psychiatric outpatient department with alcohol dependence syndrome with the onset of dependence before the commencement of COVID-19 lockdown (March 24, 2020). A senior psychiatrist diagnosed the cases per the International Classification of Diseases-10th revision. At the time of presentation, patients with acute intoxication, withdrawal state, psychotic disorder, amnesic syndrome, residual- and-late-onset psychotic disorder, other and unspecified mental and behavioral disorders due to use of alcohol and who were unable to give consent or participate in the study were excluded from the study. Patients with other comorbid psychiatric disorders, other substance dependence except for nicotine, organic brain syndrome, mental retardation, and major physical illness were also excluded from the study.
Patients were explained the study details, cleared of their doubts, and informed written consent was obtained. To minimize false reports, significant time was spent during their interviews to establish rapport and reassure the patients regarding confidentiality and their privacy. Further, information was also obtained from their family members with the patient's consent. Measures used to assess the cases included the Severity of Alcohol Dependence Questionnaire (SADQ) and a semi-structured proforma, which consisted of sociodemographic and clinical variables. The clinical variables included the amount of alcohol consumption and its source of procurement in two time periods: (1) before the commencement of the COVID-19 lockdown – on March 24, 2020, and (2) during the COVID-19 lockdown from March 24, 2020, to May 6, 2020.
Statistical analyses were done using the Statistical analysis were done using IBM SPSS Statistics for Windows, version 20.0 (IBM Corp., Armok, N.Y., USA). Descriptive statistics was employed for sociodemographic and clinical parameters. Between the two time periods: paired t-test was used to compare the alcohol usage and the cost acquired to procure them; the Chi-square test of independence was used to assess the difference in alcohol consumption among people consuming more than or equal to 90 units per week and to compare the source of procurement. Pearson's correlation test was used to assess the correlation between alcohol usage during the lockdown with the severity of alcohol dependence, cost acquired per week, and alcohol usage before lockdown. Odds ratio was used to establish the associations of illegal procurement during the lockdown. Binary logistic regression analysis predicted the risk factors associated with alcohol use of more than 90 units during the lockdown.
| Results|| |
The sociodemographic details and clinical variables of the study sample are given in [Table 1] and [Table 2], respectively. The amount of alcohol usage before and during lockdown is presented in [Table 3]. The average cost acquired per week in procuring alcohol during the lockdown showed a significant increase (mean difference = 1628.68, 95% confidence interval [CI] = 1150.89–2106.45, standard deviation = 1881.37, t = 6.816, P = 0.00) relative to period before lockdown. On categorizing the quantity of alcohol consumed per week with a cutoff value of more than or equal to 90 units, there was a significant decrease in the proportion of patients who consumed more than or equal to 90 units during the lockdown (Pearson Chi-square = 4.12, P = 0.04). During the lockdown, 6.45% of patients stopped using alcohol, mean quantity of alcohol intake per week had a strong positive correlation with SADQ (r = 0.67, P = 0.00), moderate positive correlations with mean quantity of alcohol intake (r = 0.59, P = 0.00), and cost acquired (r = 0.43, P = 0.00) per week before lockdown. Furthermore, a weak positive correlation between the mean frequency of alcohol intake per week during the lockdown and SADQ (r = 0.36, P = 0.00) was observed. Thus, alcohol usage during the lockdown was positively related to the severity of alcohol dependence syndrome, the quantity of alcohol consumed, and the cost of procurement before lockdown. The correlation was statistically significant at a 0.01 level (two-tailed).
The source of procurement of alcohol before and during lockdown is presented in [Table 4]. During the lockdown, the proportion of people procuring alcohol from the black market or used illicit liquor (Pearson Chi-square = 5.97, P = 0.01) was increased significantly and higher odds of illegal alcohol procurement were associated with subjects who were already procuring illegally or used illicit liquor before lockdown (OR = 3.81; 95% CI = 1.27–11.41; P = 0.00). Furthermore, 45.8% of people procuring illegally during the lockdown had never procured alcohol illegally before. [Table 5] shows an association between subjects consuming more than 90 units per week during the lockdown and sociodemographic and clinical variables.
|Table 5: Association between sociodemographic, clinical parameters, and subjects consuming >90 units of alcohol during lockdown (logistic regression)|
Click here to view
| Discussion|| |
This is one of the few studies that focus on alcohol-dependent patients subjected to a complete ban of liquor sale during the COVID-19 pandemic. We have analyzed the amount of alcohol usage and source of procurement before the pandemic and during the ban. Further the relationship between various sociodemographic, clinical, and psychosocial variables with continued usage of liquor during the ban was studied. We have also described their reassortment to alternate substances during the complete ban of alcohol.
In our study, the subjects were married (79%) and were living as a nuclear family (69.4%) predominantly. This contrasts culturally different western studies, where subjects of alcohol dependence syndrome were commonly separated (43%) or divorced (60%), but other Indian studies showed similar results with 62% being married. Alcohol-related problems such as domestic violence and the risk of harm to children could contribute to the possibility of an increase in domestic and intimate partner violence during the lockdown. Because in developing countries like India, where there is a high percentage of subjects with alcohol dependence being married and living in nuclear families, superimposed COVID-19 restrictions such as social isolation and closed workplaces may result in spending more time with their families leading to domestic violence.,
To combat the spread of the COVID-19 virus, countries across the world proposed various levels of restrictions to alcohol sales from physical distancing recommendations, limiting the time, and geography of availability to its complete ban of sale. The 1st month of posing such restrictions revealed an overall decrease in alcohol consumption in European countries and Canada. There are also studies which report that, in the USA, there was an increase in the number of drinks per day, the proportion of binge drinking, and liquor usage over recommended drinking limits after the stay-at-home order. In European countries, there was an increase in the prevalence of heavy drinkers during their period of restrictions. Specifically, in the UK, there was an increase in drinking patterns during the quarantine, and in Poland, there was no statistical difference in the decrease in alcohol intake.,,, Current study adds to this mixed picture of no significant change of alcohol usage during the complete ban of alcohol sales in India. This may be attributed to the net impact of an economic crisis during the pandemic where physiological distress due to unemployment and income reductions can increase drinking.
In our study, continued use of alcohol during the lockdown strongly correlated with the severity of alcohol dependence syndrome which is linked with several comorbid psychiatric disorders such as mood disorders, followed by anxiety disorders and psychotic disorders. With a greater prevalence of anxiety and depression during the COVID-19 pandemic, it could add to the psychiatric comorbidity associated with alcohol dependence. Our study also showed moderate correlations of alcohol intake during the lockdown with the quantity of alcohol usage and the expenditure toward its procurement before lockdown. This corresponds with the Australian COLLATE project listing prepandemic heavier drinking and average to higher income among other predictors to be associated with increased drinking during the pandemic. This provides options for preventive interventions before subjecting alcohol dependence patients into forced abstinence. In our study, a few patients stopped consuming alcohol during the liquor ban. As suggested in other studies, the voluntary decision is essential in continuing abstinence of substance use. The psychosocial aspect of addiction has been discussed in other studies on liquor barn and applied, especially to abstinent people who might have an increased risk of relapse.
This study also reveals an increase in the use of black-marketed and illicitly brewed liquor during the lockdown with a significant increase in expenditure toward its procurement and nearly half of patients who never used illegal liquor started to procure from the black market. This corroborates a recent study in India revealing that 62.5% of patients with alcohol use disorder who tried to procure alcohol during the lockdown were successful, and among them, 70% procured from the black market and 90% bought at a higher price. Studies abroad showed an increase in the legally buying and stockpiling of liquor before the ban, whereas in Indian studies report increased black marketing of alcohol with liquor prices rising 2–3 fold during the COVID-19 lockdown. Furthermore, previous studies on liquor ban in India due to government policies showed excessive brewing and trading of illicit liquor and subsequent deaths due to its consumption and exposure to more harmful substances and illegal activities attracting legal implications. Even though legal enforcement agencies took efforts in cutting down the black marketing of alcohol such as curbing the license of illegally trading vendors and surveying illicit brewing, their efforts were overrun by the increased demand of their services in imposing the restrictions to prevent the spread of the COVID-19 virus. Further, among various sociodemographic and clinical variables in our study, the subjects who were previously exposed to illegal buying or using illicit alcohol had higher odds of illegal procurement during the lockdown. This warrants stringent measures against the illegal availability of liquor even during the pre- or postlockdown period.
The evidence of an increase in the use of alternate substances of abuse such as nicotine and cannabis during the lockdown suggests an increase in the probability for patients to experience additional harmful effects and be dependent on more than one substance of abuse. This corresponds with the survey in 21 European countries where tobacco and cannabis use increased during the initial phase of COVID-19 restrictions. This study also shows that people consumed more than 90 units of alcohol per week during lockdown at which level inpatient detoxification may have been needed. This highlights the concern raised in other studies about the possibility of alcohol users having withdrawal symptoms and unable to access a hospital during the total lockdown. Predicting factors for such high levels of consumption during the lockdown include rural residential location, moderate-income bracket, low socioeconomic class, and severe alcohol dependence. These factors help to target specific groups of people with alcohol dependence for effective forced abstinence, especially at times when hospital care may not be accessible.
Since the current study is not a longitudinal study, it tells us about the pattern of use and its procurement at that specific time period. The impact of COVID-19 restrictions is to be studied on a longitudinal basis to know long-term patterns of use and associated factors with alcohol dependence syndrome.
| Conclusion|| |
Availability restriction of alcohol during the COVID-19 pandemic in India showed increased procurement of black market and illicitly brewed liquor. Although alcohol consumed did not significantly differ, money spent toward procurement increased during the lockdown. Alcohol dependence patients from rural residential locations with moderate income brackets, low socioeconomic class, and severe alcohol dependence could be key target groups for effective interventions, particularly at places of reduced hospital resources. Thus, the legal ban of liquor sales did not benefit alcohol dependence patients, and such restriction availability strategies may benefit from additional regulation of alcohol brewing and sales along with adequate treatment facilities for the complications of alcohol dependence, health awareness, treatment, and psychosocial support.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet 2009;373:2223-33.
Ambekar A, Agrawal A, Rao R, Mishra AK, Khandelwal SK, Chadda R. National Survey on Extent and Pattern of Substance Use in India (2019). Magnitude of Substance Use in India. New Delhi: Ministry of Social Justice and Empowerment, Government of India; 2019.
Eashwar VM, Umadevi R, Gopalakrishnan S. Alcohol consumption in India – An epidemiological review. J Family Med Prim Care 2020;9:49-55.
] [Full text]
Rush BR, Gliksman L, Brook R. Alcohol availability, alcohol consumption and alcohol-related damage. I. The distribution of consumption model. J Stud Alcohol 1986;47:1-10.
Popova S, Giesbrecht N, Bekmuradov D, Patra J. Hours and days of sale and density of alcohol outlets: Impacts on alcohol consumption and damage: A systematic review. Alcohol Alcohol 2009;44:500-16.
Pereira G, Wood L, Foster S, Haggar F. Access to alcohol outlets, alcohol consumption and mental health. PLoS One 2013;8:e53461.
Anderson P, Chisholm D, Fuhr DC. Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. Lancet 2009;373:2234-46.
Sanchez-Ramirez DC, Voaklander D. The impact of policies regulating alcohol trading hours and days on specific alcohol-related harms: A systematic review. Inj Prev 2018;24:94-100.
Casswell S, Morojele N, Williams PP, Chaiyasong S, Gordon R, Gray-Phillip G, et al.
The alcohol environment protocol: A new tool for alcohol policy. Drug Alcohol Rev 2018;37 Suppl 2:S18-26.
Nadkarni A, Kapoor A, Pathare S. COVID-19 and forced alcohol abstinence in India: The dilemmas around ethics and rights. Int J Law Psychiatry 2020;71:101579.
World Health Organization. ICD-10: International Statistical Classification of Diseases and Related Health Problems: Tenth Revision. Geneva, Switzerland: WHO Press; 2004. Available from: https://apps.who.int/iris/handle/10665/42980
. [Last accessed on 2021 Dec 07].
Reddy MP, Babu RS, Pathak SM, Venkateshwarlu S. The clinical and demographic profile of male patients with alcohol dependence syndrome. Indian J Psychol Med 2014;36:418-21.
] [Full text]
Ramalho R. Alcohol consumption and alcohol-related problems during the COVID-19 pandemic: A narrative review. Australas Psychiatry 2020;28:524-6.
Kilian C, Rehm J, Allebeck P, Braddick F, Gual A, Barták M, et al.
Alcohol consumption during the COVID-19 pandemic in Europe: A large-scale cross-sectional study in 21 countries. Addiction 2021;116:3369-80.
Rossow I, Bartak M, Bloomfield K, Braddick F, Bye EK, Kilian C, et al.
Changes in Alcohol consumption during the COVID-19 pandemic are dependent on initial consumption level: Findings from Eight European Countries. Int J Environ Res Public Health 2021;18:10547.
Minhas M, Belisario K, González-Roz A, Halladay J, Murphy JG, MacKillop J. COVID-19 impacts on drinking and mental health in emerging adults: Longitudinal changes and moderation by economic disruption and sex. Alcohol Clin Exp Res 2021;45:1448-57.
Barbosa C, Cowell AJ, Dowd WN. Alcohol consumption in response to the COVID-19 pandemic in the United States. J Addict Med 2021;15:341-4.
de Goeij MC, Suhrcke M, Toffolutti V, van de Mheen D, Schoenmakers TM, Kunst AE. How economic crises affect alcohol consumption and alcohol-related health problems: A realist systematic review. Soc Sci Med 2015;131:131-46.
Santomauro DF, Mantilla Herrera AM, Shadid J, Zheng P, Ashbaugh C, Pigott DM, et al
. Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic. Lancet 2021;398:1700-12. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0140673621021437
. [Last accessed on 2021 Dec 14].
Neill E, Meyer D, Toh WL, van Rheenen TE, Phillipou A, Tan EJ, et al.
Alcohol use in Australia during the early days of the COVID-19 pandemic: Initial results from the COLLATE project. Psychiatry Clin Neurosci 2020;74:542-9.
Balhara YP, Singh S, Narang P. Effect of lockdown following COVID-19 pandemic on alcohol use and help-seeking behavior: Observations and insights from a sample of alcohol use disorder patients under treatment from a tertiary care center. Psychiatry Clin Neurosci 2020;74:440-1.
Manthey J, Kilian C, Carr S, Bartak M, Bloomfield K, Braddick F, et al.
Use of alcohol, tobacco, cannabis, and other substances during the first wave of the SARS-CoV-2 pandemic in Europe: A survey on 36,000 European substance users. Subst Abuse Treat Prev Policy 2021;16:36.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]