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SallieSN, etal. BMJ Open 2020;10:e044276. doi:10.1136/bmjopen-2020-044276
Open access
Assessing international alcohol
consumption patterns during isolation
from the COVID-19 pandemic using an
online survey: highlighting negative
emotionality mechanisms
Samantha N Sallie ,1 Valentin Ritou,2 Henrietta Bowden- Jones,1,3 Valerie Voon1
To cite: SallieSN, RitouV,
Bowden- JonesH, etal.
Assessing international
alcohol consumption patterns
during isolation from the
COVID-19 pandemic using
an online survey: highlighting
negative emotionality
mechanisms. BMJ Open
2020;10:e044276. doi:10.1136/
bmjopen-2020-044276
►Prepublication history and
additional materials for this
paper is available online. To
view these les, please visit
the journal online (http:// dx. doi.
org/ 10. 1136/ bmjopen- 2020-
044276).
Received 28 August 2020
Revised 02 November 2020
Accepted 03 November 2020
1Department of Psychiatry,
University of Cambridge,
Cambridge, UK
2Faculty of Basic and Biomedical
Sciences, University of Paris,
Paris, France
3Faculty of Brain Sciences,
University College London,
London, UK
Correspondence to
Samantha N Sallie;
sns36@ cam. ac. uk
Original research
© Author(s) (or their
employer(s)) 2020. Re- use
permitted under CC BY.
Published by BMJ.
ABSTRACT
Objectives The COVID-19 pandemic has required
drastic safety measures to control virus spread, including
an extended self- isolation period. Stressful situations
increase alcohol craving and consumption in alcohol use
disorder (AUD) and non- AUD drinkers. Thus, we assessed
how COVID-19 related stress may have affected drinking
behaviours in the general population.
Design We developed an online cross- sectional survey,
Habit Tracker (HabiT), which measured changes in drinking
behaviours before and during COVID-19 quarantine.
We also assessed psychiatric factors such as anxiety,
depression (Hospital Anxiety and Depression Scale) and
impulsivity (Short- Impulsive Behavior Scale). Lastly, we
related drinking behaviours to COVID-19 specic stress
factors.
Setting HabiT was released internationally, with
individuals from 83 countries participating.
Participants Participants were included if they were 18
years of age or older and conrmed they were procient
in English. The survey was completed by 2873 adults with
1346 usable data (46.9% accurately completed).
Primary outcome measures Primary outcome
measures were change in amount and severity of drinking
behaviours before and during quarantine, and current
drinking severity during quarantine.
Results Although drinking behaviours decreased overall
during quarantine, 36% reported an increase in alcohol
use. Those who increased alcohol use during quarantine
were older individuals (95% CI 0.04 to 0.1, p<0.0001),
essential workers (95% CI −0.58 to −0.1, p=0.01),
individuals with children (95% CI −12.46 to 0.0, p=0.003),
those with a personal relationship with someone severely
ill from COVID-19 (95% CI −2 to −0.38, p=0.01) and those
with higher depression (95% CI 0.67 to 1.45, p<0.0001),
anxiety (95% CI 0.61 to 1.5, p=0.0002), and positive
urgency impulsivity (95% CI 0.16 to 0.72, p=0.009).
Furthermore, country- level subsample analyses indicated
that drinking amount (95% CI 9.36 to 13.13, p=0.003)
increased in the UK during quarantine.
Conclusions Our ndings highlight a role for identifying
those vulnerable for alcohol misuse during periods of
self- isolation and underscore the theoretical mechanism
of negative emotionality underlying drinking behaviours
driven by stress. Limitations include a large degree of
study dropout (n=1515). Future studies should assess the
long- term effects of isolation on drinking behaviours.
INTRODUCTION
The COVID-19 pandemic has necessitated
drastic safety measures to control the virus
spread. These measures included an extended
self- isolation period in which individuals were
permitted to leave their places of residence
only to obtain amenities (eg, food, medical
care, and toiletries) or engage in essential
work. Individuals were not permitted face- to-
face contact with anyone who did not reside
within their immediate households. In the
UK, these measures were instituted nation-
ally on 23 March 2020, with a gradual lifting
of restrictions on 10 May 2020, ending on 4
July 2020 with locality- specific intermittent
reinstatement of these measures. Although
a necessary precautionary measure to miti-
gate the devastating effects of COVID-19
on public health, evidence indicates that
protracted periods of self- isolation, especially
in the context of stress, may be related to
acute and prolonged negative mental health
Strengths and limitations of this study
►The Habit Tracker (HabiT) study sampled drinking
behaviours of a large, diverse population during the
COVID-19 pandemic.
►Changes in drinking behaviours were assessed
against specic COVID-19 related stress factors.
►Due to the length of the survey (8–10 min), we ob-
served a large degree of study dropout.
►Subjects were within varying phases of lockdown
during the time of testing.
►The prevalence of diagnosed alcohol use disorder
drinkers sampled was low, likely related to sampling
issues or under- reporting.
2SallieSN, etal. BMJ Open 2020;10:e044276. doi:10.1136/bmjopen-2020-044276
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consequences, particularly in individuals already strug-
gling with psychiatric disorders.1
Indeed, current clinical reports from individuals in
treatment for substance abuse disorder indicate that the
stress produced by COVID-19 social isolation measures
have triggered greater and more frequent drug or
alcohol cravings, subsequently leading to relapse.2 This
observation is relevant to a prominent mechanistic theory
of negative emotionality underlying alcohol misuse.3 The
relationship between stress and alcohol consumption
is widely recognised and can be observed in an experi-
mental fashion.4 In subjects with known alcohol use
disorder (AUD), stress and experimental manipulations
of stress enhance the amount of alcohol consumed,5 6
alcohol craving,7 problematic drinking behaviours, and
likelihood of relapse.8 Exposure to stress triggers relapse
characterised by a reinstantiation of alcohol cravings and
alcohol- seeking behaviours.
Increases in alcohol craving and consumption after
stress exposure also occur in those without AUD. An
increase in alcohol consumption is often used as a coping
strategy for both chronic and specific stressful life events
in both AUD and non- AUD drinkers.9 Similarly in both
groups, self- reported craving and subjective judgements
of alcohol value rise following a stress task,10 and social
drinkers consume more alcohol after witnessing a social
stressor.11 These relationships are moderated by gender,12
age,13 previous alcohol exposure,13 alcohol expectancies,14
and the pattern of alcohol consumption.15 Furthermore,
psychiatric symptomology such as anxiety and depression
as well as pathological levels of personality traits such as
impulsivity are widely recognised predisposing factors to
problematic alcohol use and addiction.3 16
Thus, in response to these exceptional circumstances,
we aimed to assess how social isolation measures in the
midst of the COVID-19 pandemic may have affected
drinking behaviours in the general adult population. We
developed an international survey, entitled Habit Tracker
(HabiT), which evaluated drinking severity before
(post- hoc recall) and during the COVID-19 quarantine
period. We hypothesised that changes in amount of
alcohol consumption and severity of drinking behaviours
may be related to specific COVID-19 related stress factors,
as well as demographic and psychiatric factors. Further-
more, we investigated if COVID-19 related stress factors
influenced changes in drinking amount, drinking severity,
depression, and anxiety before and during quarantine.
METHODS
Recruitment and inclusion criteria
The HabiT survey was a questionnaire that sought to
assess the effects of isolation on alcohol, smoking, and
internet use. The effects on alcohol use are reported
here. Subjects were included if they were 18 years of age
or older and confirmed they were proficient in reading
and understanding English. HabiT was advertised by
University of Cambridge news page on 11 May 2020, a day
before its international release. For the next several days,
the survey was disseminated by news agencies throughout
the UK (eg, The Telegraph, BBC Cambridgeshire and
News Wise) as well as throughout various University of
Cambridge colleges. Furthermore, the survey was posted
and shared on personal and public social media sites
(ie, Facebook and Twitter). All subjects gave informed
consent and were not financially compensated for their
participation, although informed that—on survey comple-
tion–they would be provided results of the study through
request. The data collected was fully anonymised. The
survey was created using Qualtrics (Provo, Utah) survey-
building platform. Developed iteratively within- lab and
among coauthors to insure brevity and consistency, the
average time to complete the survey was approximately
8–10 min, and all subjects could participate on either a
computer or smartphone device.
Patient and public involvement statement
We did not involve patients or the public in the research
design, reporting, or survey dissemination strategies of
this study.
Demographic information
The demographic information collected were as follows:
age, gender, socioeconomic status, intimate relationship
status, country and city of residence, and any previous
or current diagnosis of a psychiatric or neurological
disorder.
Attentional checks
Every major section of the survey contained at least one
question that served as an attentional check to ensure
subjects were correctly reading and answering survey
questions to the best of their ability. The attentional
checks were structured to mirror the Likert scaling of
each section (eg, ‘If you are reading this question, please
select “Strongly Agree.”’).
Frequency and severity of alcohol consumption before and
during the quarantine period
We first asked subjects if they drank alcohol. If the answer
was negative, they proceeded to the next set of questions.
If the answer was positive, we assessed the change in the
amount and severity of alcohol use as well as the current
severity of alcohol use. We asked subjects to report the
following behaviours within a typical week in November
(ie, pre- quarantine) and within the last week (ie,
during quarantine): (1) the number of units of alcohol
consumed within the last week with examples for the
number of units for differing types of alcohol and sizes
provided; and (2) the change in severity using a times-
cale adaptation of the first three questions of the Alcohol
Use Disorders Identification Test, which assessed the
amount and frequency of alcohol consumption (AUDIT-
C).17 Subjects were asked to report how many days in
the last week they consumed an alcoholic beverage, how
many drinks they consumed on a typical day they were
drinking in the last week, and how often they consumed
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six or more drinks on one occasion in the last week. To
assess the current severity of drinking behaviours during
quarantine, we used a timescale- adapted version of the
full Alcohol Use Disorders Identification Test (AUDIT),18
which assessed problem drinking behaviours within
the last week such as an inability to stop drinking once
started, failure to perform responsibilities, feeling guilt
or remorse, drinking shortly after waking to ease the
adverse physiological effects of drinking the night before,
drinking to the point of memory loss, injuring oneself or
others due to drinking, and concern from a loved one or
medical professional related to the amount or severity of
one’s drinking. We used two primary outcome measures:
the change in severity (AUDIT- C), corroborated with the
secondary change in amount of drinking (units per week)
and current severity (full AUDIT).
COVID-19 related stress factors
We assessed 10 factors that may contribute to COVID-19
related stress using the following questions:
1. Have you been deemed an ‘essential worker’ by your
government?
2. Do you work for healthcare services specifically
with individuals who have contracted COVID-19?
(Subquestion of question 1)
3. Has your employment situation changed due to the
COVID-19 crisis?
4. Has anyone you know personally contracted or have
shown symptoms characteristic of COVID-19?
5. Has anyone you know personally become severely ill
or died due to contracting COVID-19?
6. Are you isolated alone?
7. Do you have children?
8. If you have children, are you their only caretaker?
(Subquestion of question 7).
9. If you are currently in isolation with others, how
would you describe the quality of your relations?
10. How often do you currently go outdoors (for work,
essential duties, leisure and so on)?
Psychiatric measures
Depression and anxiety symptomatology were measured
using The Hospital Anxiety and Depression Scale
(HADS), a brief, validated four- item questionnaire.19 As a
secondary analysis, we assessed impulsivity using the vali-
dated Short Impulsive- Behavior Scale (SUPPS- P).20 This
scale provides an overall impulsivity score, as well as five
scores corresponding to impulsivity subscales: persevera-
tion, lack of premeditation, sensation seeking, negative
urgency, and positive urgency.
Statistical analysis
Statistical analyses were performed using MATLAB
(V.2020a). All subjects who answered the attentional
checks incorrectly (n=12), reported highly improbable
answers regarding the units of alcohol they consumed
weekly (eg, 1000 units), did not report their gender, or
did not complete the psychiatric questionnaires were
excluded from further analysis; leaving a total of 1346
subjects. Drinking severity scores of the sample were non-
normally distributed (Shapiro- Wilk, p<0.05), thus non-
parametric tests were used.
We used Mann- Whitney U tests to compare weekly
alcohol unit consumption and alcohol severity before and
during quarantine in the full group. Then, we divided
subjects into three groups, those who during quaran-
tine either increased, decreased, or did not change their
alcohol consumption, and performed a Kruskal- Wallis
H- test to assess the relative drinking amount to severity
indices of these groups.
We then assessed which COVID-19 related stress factors
were associated with changes in either amount (alcohol
units consumed per week), change in severity (AUDIT-
C), current severity (full AUDIT), or current depres-
sion and anxiety (HADS) using the following tests: (1)
Mann- Whitney U tests to compare negative versus positive
responses to the COVID-19 stress factors (MW), (2) multi-
variate analysis of covariance (MANCOVA)21 controlling
for gender and age (MAN1), and (3) a second MANCOVA
controlling for age, gender, depression, and anxiety symp-
tomology (MAN2). For the MANCOVA tests, variables
‘age,’ ‘depression severity,’ and ‘anxiety severity’ were
dichotomised via median split. For the COVID-19 stress
primary factor comparisons (eight items), we used False
Discovery Rate (FDR) to control for multiple comparisons
with significance assigned at p<0.05.22 23 95% confidence
intervals (CIs) are provided with p- values for significant
findings observed from the most stringent statistical test.
On an exploratory basis, we then used Spearman’s partial
correlations to compare the drinking severity indices of
subjects who completed the timescale- adapted full AUDIT
with SUPPS- P and HADS scores to relate drinking severity
of the overall sample to psychiatric measures. Lastly,
in order to assess possible directional relationships in
changes in the severity of drinking behaviours to depres-
sion, anxiety, and impulsivity, we performed Spearman’s
partial correlations with the psychiatric questionnaires
among the three aforementioned groups (ie, increased,
decreased, and null). For both correlational analyses, we
used FDR correction (p<0.05) for multiple comparisons.
RESULTS
Demographic information
A total of 2873 subjects participated (data collection: 12
May 2020–28 May 2020) of which 1346 had usable data
based on defined criteria (1515 dropouts; 46.9% accu-
rately completed; please refer to the supplementary
materials for a demographic analysis of those who did
not complete the survey). Of these subjects, 859 (63.8%)
reported that they drink alcohol (please refer to the
online supplemental materials for demographic infor-
mation on those who reported drinking alcohol). Of the
1346 subjects, the average age was 28.92±10.45 years (95%
CI 28.2 to 29.53) (range=18–90) with more males (males:
n=1006; females: n=325; other: n=15) from 85 different
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countries of residence, with the majority from the UK
(n=434) and the USA (n=355), followed by Canada
(n=64) and Germany (n=63). Marital status was as follows:
single: n=785; married or committed: n=571; divorced or
separated: n=33; widowed: n=4. Socioeconomic status (as
denoted by annual income in raw currency on the country
level and converted to UK pounds during analysis) was
as follows: <19.9k: n=285; 20–39.9 k: n=273; 20–39.9 k:
n=244; 40–69.9 k: n=241; 70–99.9 k: n=141;>100k: n=203;
and 232 subjects did not report their incomes. Current
psychiatric or neurological diagnoses were as follows: no
diagnosis: n=1192; depression: n=60; anxiety: n=38; post-
traumatic stress disorder: n=5; and comorbid depression
and anxiety: n=46.
Overall changes in drinking frequency and severity before and
during quarantine
Of the total sample, the change in problem drinking severity
(AUDIT- C) was 0.89±1.43 (95% CI 0.81 to 0.96) (range:
0–8) and the mean change in the amount consumed was
5.62±9.55 units per week (95% CI 3.16 to 4.02) (range:
0–120). The current problem drinking severity (full
AUDIT) was 3.14±4.47 (95% CI 2.9 to 3.37) (range: 0–32),
with 557 subjects included that do not consume alcohol. Of
the subjects who reported they consume alcohol (n=859),
the change in severity from prequarantine to quarantine
was a decrease of 1.53±1.6 (95% CI 5.01 to 5.64), range
0–8 (U=2.65 (95% CI 0 to 0.21) p=0.008). The units of
alcohol consumed per week was significantly decreased
during the quarantine period (8.03±14.22 units (7.11–8.94)
range=1–120) compared with November (8.32±11.92 units
(95% CI 7.47 to 9.02) range=0–150), U=−2.29 (95% CI 0.0
to 0.0) p=0.02 (figure 1). However, in the UK, the units
of alcohol consumed per week was significantly increased
during the quarantine period (11.25±17.73 units (95%
CI 9.36 to 13.13) range=1–120) compared to November
(10.94±14.17 units (95% CI 9.44 to 12.45) range=0–150),
U=3.0 (95% CI 0 to 0.7) p=0.003. (For full country- level
subanalyses of drinking behaviours, as well as severity of
lockdown and amount of confirmed COVID-19 cases and
deaths during the data collection period by country via
Coronavirus Government Response Tracker,24 please refer
to the online supplemental materials). Of the international
sample, 172 (20%) subjects reported abstention from
alcohol consumption during the quarantine period. More
subjects reported a decrease (n=384, 45%) or an increase
(n=308, 36%) as opposed to no change (n=166, 19%) of
weekly alcohol consumption from November to the quar-
antine period (χ2=72.86, p=0.001; figure 1). Of the three
Figure 1 Changes in amount and severity of drinking behaviours in the HabiT sample between prequarantine and quarantine
periods. Units of alcohol consumed weekly (top left) and changes in drinking severity (AUDIT- C) (bottom right) decreased during
the quarantine period and more individuals either increased or decreased their weekly units consumed during quarantine than
remained the same (top right). Furthermore, those who increased their weekly alcohol unit consumption during the quarantine
period had signicantly higher drinking severity indices (full AUDIT) compared with those who decreased or did not change their
drinking behaviours during the quarantine period (bottom left). AUDIT, Alcohol Use Disorders Identication Test; HabiT, Habit
Tracker.
5
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groups, those who: (1) increased weekly units consumed
during quarantine (7.5±10.5 change in units (95% CI 6.33
to 8.7) range: 1–80), (2) decreased weekly units consumed
during quarantine (−6.5±9.5 change in units (95% CI −7.45
to −5.55) range: −0.2 to −120), and (3) did not change their
weekly unit consumption, subjects who had increased the
units of alcohol consumed during the quarantine period
showed significantly higher current drinking severity scores
(7.5±5.6 (95% CI 6.89 to 8.15) range: 1–32) than those who
reported decreases (3.5±3.0 (95% CI 3.16 to 3.76) range:
1–21) or no changes (4.8±3.6 (95% CI 4.17 to 5.23) range:
1–20) in weekly unit consumption (H=165.33 (95% CI 3.35
to 4.78) p<0.0001, figure 1).
COVID-19 stress factor evaluation
The change in amount of drinking was positively correlated
with age (rs=0.2 (95% CI 0.04 to 0.1) p<0.0001) and gender
with males (6.44±10.8 units (95% CI 5.63 to 7.35) range:
0–120) showing an increased change in drinking amount
relative to females (3.81±5.18 (95% CI 3.08 to 4.32) range:
0–38), or other genders (1.32±1.65 (95% CI 0.18 to 2.24)
range: 0–5) (H=8.17, p=0.003). Changes in drinking
severity were also related to both age and gender, with
older individuals (rs=0.2 (95% CI 0.01 to 0.02) p<0.0001)
and males (1.68±1.74 (95% CI 1.55 to 1.83) range: 0–8)
demonstrating greater changes in their drinking severity
than females (1.16±1.12 (95% CI 1.02 to 1.3) range: 0–8),
and others (1.36±1.29 (95% CI 0.54 to 2.18) range: 0–3)
(H=6.02 (95% CI −0.81 to −0.22) p=0.05). (Age- and gender-
specific subanalyses of drinking behaviours can be found in
the online supplemental materials). Thus, we used age and
gender as covariates for both MANCOVA analyses. All rele-
vant covariates used in these analyses were dichotomised
via median split (age=25.1 years, depression severity=2, and
anxiety severity=1).
Primary COVID-19 stress factors
The influence of COVID-19 stress factors on the change in
drinking severity, amounts consumed, and current drinking
severity are reported in tables 1–3, respectively. Desig-
nated essential workers and those with children showed a
greater increase in the amount consumed weekly, drinking
severity, and greater current severity. This remained signifi-
cant including when controlled for demographic variables
(age and gender) and psychiatric symptoms (depression
and anxiety). Notably, although subjects with children
reported an increase in the number of units of alcohol and
severity of alcohol use, they also reported lower levels of
depression and anxiety. Knowing an individual personally
who was ill or severely ill with COVID-19 showed higher
current alcohol drinking severity than those who did not,
but with no change from prequarantine to postquarantine.
A reported change in employment status and isolating
alone was associated with greater depression scores, with
no differences in drinking behaviours. Isolating with others
but reporting a poor quality relationship was associated
with greater depression and anxiety; however, the lower
drinking behaviours were moderated by age and gender
effects. Finally, going outdoors was associated with greater
current drinking severity and greater depression and
anxiety scores controlling for all variables. Post hoc tests
confirmed that, in cases in which a significant relationship
was lost between an item and either changes in drinking
amount or severity due to controlling for age and gender
(ie, MANCOVA 1), age was the sole contributor (essential
worker: F(1, 533.2)=7 (95% CI 0.15 to 2.1) p=0.008; others
ill: F(1, 879.9)=52.6 (95% CI 1.7 to 2.7) p<0.0001; poor rela-
tionship: F(1, 933.9)=48.88 (95% CI 1.8 to 2.8) p<0.0001).
Secondary COVID-19 stress factors
Two COVID-19 stress factors were considered secondary
as they represented a subset of a primary factor. Working
for healthcare services was associated with a trend towards
Table 1 COVID-19 primary stress items relationship with changes in drinking severity (as indexed by the AUDIT- C) from
prequarantine to quarantine.
Stress factor N total
Yes
M (SD)
N
Yes
No
M (SD)
N
No
MW
P value
MAN1
P value
MAN2
P value 95% CI
Essential worker 1337 0.16 (1.9) 241 −0.21 (1.6) 1096 0.02* 0.01* 0.01* −0.58 to −0.1
Employment 1337 −0.14 (1.8) 323 −0.14 (1.6) 1014 0.83 0.96 0.92
Others ill 1334 −0.17 (1.8) 497 −0.12 (1.6) 837 0.75 0.64 0.63
Others severely ill 1336 −0.01 (2) 127 −0.15 (1.6) 1209 0.35 0.7 0.69
Isolated alone 1325 −0.1 (1.9) 168 −0.15 (1.6) 1157 0.83 0.85 0.82
Having children 1334 0.34 (1.4) 209 −0.23 (1.7) 1125 <0.0001* 0.005* 0.003* −12.46 to 0.0
Poor relationship 1168 −0.3 (1.7) 187 −0.13 (1.6) 981 0.35 0.7 0.69
Going outdoors 1336 −0.27 (1.3) 193 −0.12 (1.7) 1143 0.26 0.7 0.69
95% condence interval (CI) for most stringent statistically signicant nding.
*p- value indicates statistical signicance.
AUDIT- C, Alcohol Use Disorders Identication Test; M, mean; MAN1 p- value, MANCOVA p- value controlling for age and gender; MAN2
p- value, MANCOVA p- value controlling for age, gender, depression, and anxiety; MW p- value, Mann- Whitney U- Test p- value; SD,
standard deviation.
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Table 2 COVID-19 primary stress items relationship with changes in drinking amount (in units) from prequarantine to
quarantine.
Stress factor N total
Yes
M (SD)
N
Yes
No
M (SD)
N
No
MW
P value
MAN1
P value
MAN2
P value 95% CI
Essential worker 1337 1.26 (12.8) 241 0.45 (7.5) 1096 0.0003* 0.07 0.08 −3.4 to −0.02
Employment 1337 0.17 (11.2) 323 0.13 (7.8) 1014 0.77 0.95 0.97
Others ill 1334 0.05 (7.1) 497 0.2 (9.6) 837 0.83 0.95 0.97
Others severely ill 1336 0.06 (7.6) 127 0.15 (8.9) 1209 0.83 0.95 0.97
Isolated alone 1325 0.05 (11.6) 168 0.2 (8.2) 1157 0.46 0.95 0.97
Having children 1334 2.02 (11.9) 209 0.54 (7.9) 1125 <0.0001* 0.04* 0.02* −3.6 to −0.74
Poor relationship 1168 0.4 (6.1) 187 0.19 (8.7) 981 0.46 0.95 0.97
Going outdoors 1336 1.23 (6.8) 193 0.04 (9.0) 1143 0.15 0.47 0.4
95% condence interval (CI) for most stringent statistically signicant nding.
*p- value indicates statistical signicance.
M, mean; MAN1 p- value, MANCOVA p- value controlling for age and gender; MAN2 p- value, MANCOVA p- value controlling for age,
gender, depression, and anxiety; MW p- value, Mann- Whitney U- Test p- value; SD, standard deviation.
Table 3 COVID-19 primary stress items relationship with current drinking severity (ie, full AUDIT), depression and anxiety from
prequarantine to quarantine.
Stress factor
N
Total Severity type
Yes
M (SD)
N
Yes
N
M (SD)
N
No
MW
P value
MAN1
P value
MAN2
P value 95% CI
Essential
worker
1337 Drinking 4.42 (5.7) 243 2.85 (4.1) 1099 <0.0001* 0.0005* 0.0005* −1.8 to −057
Depression 2.29 (1.8) 243 2.44 (1.9) 1099 0.43 0.84
Anxiety 1.79 (1.7) 243 1.94 (1.8) 1099 0.42 0.8
Employment
change
1337 Drinking 3.46 (4.9) 324 3.02 (4.3) 1018 0.38 0.08 0.144
Depression 2.78 (2.0) 324 2.31 (1.9) 1018 0.0043* 0.007* −0.58 to −0.1
Anxiety 2.03 (4.5) 324 1.88 (1.8) 1018 0.32 0.363
Others ill 1334 Drinking 3.59 (1.9) 499 2.87 (4.4) 840 <0.0001* 0.1 0.125 −1.2 to −0.2
Depression 2.3 (1.8) 499 2.47 (1.9) 840 0.20 0.83
Anxiety 1.9 (5.5) 499 1.93 (1.9) 840 0.99 0.94
Others
severely ill
1336 Drinking 4.49 (2.0) 127 2.99 (4.3) 1214 0.001* 0.007* 0.01* −2 to −0.38
Depression 2.45 (2.0) 127 2.4 (1.9) 1214 0.99 0.41
Anxiety 1.92 (5.8) 127 1.91 (1.8) 1214 0.82 0.84
Isolated alone 1325 Drinking 3.88 (2.0) 169 2.98 (4.2) 1161 0.42 0.83 0.87
Depression 3.4 (1.9) 169 2.41 (1.9) 1161 0.009* 0.04* −0.7 to −0.06
Anxiety 2.04 (5.2) 169 1.9 (1.8) 1161 0.43 0.11
Having
children
1334 Drinking 5.17 (1.8) 211 2.75 (4.2) 1128 <0.001* 0.0003* <0.0001* −2.4 to −0.9
Depression 1.5 (1.7) 211 2.58 (1.9) 1128 <0.0001* <0.0001* 0.37 to 0.97
Anxiety 1.37 (1.7) 211 2.02 (1.9) 1128 <0.0001* 0.0009* 0.25 to 0.85
Poor
relationship
1168 Drinking 2.82 (5.1) 187 3.1 (4.1) 985 0.01* 0.92 0.87 0.4 to 1.0
Depression 3.57 (2.0) 187 2.2 (1.8) 985 <0.0001* <0.0001* −1.53 to −1
Anxiety 2.79 (2.0) 187 1.74 (1.8) 985 <0.0001* <0.0001* −1.3 to −073
Going
outdoors
1336 Drinking 3.42 (4.5) 1148 1.37 (3.4) 193 <0.0001* <0.0001* <0.0001* 1.14 to 2.47
Depression 3.18 (2.0) 193 2.28 (1.9) 1148 <0.0001* <0.0001* −1 to −0.42
Anxiety 2.42 (2.0) 193 1.83 (1.8) 1148 0.0002* 0.0008* −0.8 to −0.24
95% condence interval (CI) for most stringent statistically signicant nding.
*p- value indicates statistical signicance.
AUDIT, Alcohol Use Disorders Identication Test; M, mean; MAN1 p- value, MANCOVA p- value controlling for age and gender; MAN2 p- value,
MANCOVA p- value controlling for age, gender, depression, and anxiety; MW p- value, Mann- Whitney U- Test p- value; SD, standard deviation.
7
SallieSN, etal. BMJ Open 2020;10:e044276. doi:10.1136/bmjopen-2020-044276
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a greater change in amount of units consumed (F=3.97
(95% CI −6.73 to −0.0), p=0.05) and greater severity of
current drinking (F=7.01 (95% CI −3.9 to −0.6) p=0.007)
when controlled for all variables. Being the only caretaker
for children was also associated with greater change in
drinking severity (U=2.62 (95% CI −2.7 to −0.9) p=0.009)
and greater change of amount consumed (U=2.67 (95%
CI −4.5 to −0.8) p=0.007) but was no longer significant
when controlling for age and gender.
Drinking severity during quarantine and correlations with
psychiatric measures
Of the individuals who reported drinking alcohol, (n=769)
completed the current drinking severity index (eg, the
adapted- timescale full AUDIT). The severity of drinking
behaviours was positively related to depression (rs=0.12
(95% CI 0.34 to 0.79) p=0.004), anxiety (rs=0.12 (95%
CI 0.3 to 0.74) p=0.027) and positive urgency impulsivity
(rs=0.12 (95% CI 0.14 to 0.34) p=0.004), controlled for
age and gender. To assess potential directional relation-
ships between current drinking severity during quaran-
tine and psychiatric measures, we correlated depression,
anxiety, and impulsivity with the three drinking groups
(ie, increased, decreased and null). Drinking severity
scores in the decreased and no change groups were
not significantly correlated with any of the psychiatric
measures of interest. However, drinking severity of those
who increased their units consumed during the quaran-
tine period were related to depression (rs=0.30 (95% CI
0.67 to 1.45) p<0.0001), anxiety (rs=0.23 (95% CI 0.61 to
1.5) p=0.0002), and positive urgency (rs=0.17 (95% CI
0.16 to 0.72) p=0.009) (figure 2).
DISCUSSION
We show an overall decrease in amounts and severity of
problem alcohol use from prequarantine to the quaran-
tine period. Critically, however, three different subpop-
ulations were identified, with most either increasing or
decreasing use as compared with remaining unchanged
in their alcohol use behaviours. Greater drinking
was associated with demographic factors including
age, COVID-19 stress- related factors, and psychiatric
factors such as depression, anxiety, and the impulsivity
subscale of positive urgency. Increases in drinking were
also region- specific; with UK residents demonstrating
an upswing in weekly amount of alcohol consumed
during quarantine. Our findings underscore the theo-
retical mechanism of negative emotionality underlying
drinking behaviours driven by stress, depression and,
anxiety.
An overall decrease in alcohol consumption and prob-
lematic use may have multiple, potential aetiologies.
Stringent lockdown may be associated with a decrease in
the presence or availability of alcoholic beverages within
the immediate household given limitations in access, a
decrease in exposure to alcohol cues that may trigger
urges, or the preference to consume alcohol within
social contexts. More subjects reported either decreasing
or increasing the frequency of their alcohol intake
compared to remaining unchanged, consistent with
previous reports of a greater tendency towards extremes
in individual drinking patterns when faced with either
acute or chronic life stressors.15
Older individuals showed a greater increase in drinking
behaviours during lockdown and current severity of
problem drinking, consistent with demographic factors
known to be associated with alcohol misuse. Whether
one increases their drinking after experiencing acute or
chronic life stress is age dependent, which may reflect a
function of previous alcohol experience.13 Age may play a
particularly unique role in the context of COVID-19 due
to the greater need for stringent isolation with age, poten-
tially fewer supports, and the risk of greater isolation,
loneliness, and concern about the impact of COVID-19
on one’s personal health. Expectedly, males showed
greater unit consumption compared with females and
other genders overall. However, males showed a decrease
in both drinking amount and severity during quarantine,
while females demonstrated the opposite trend. This
finding corroborates evidence that indicates females are
Figure 2 Regression plots of the signicant relationships between drinking severity and psychiatric measures in subjects
who increased weekly alcohol unit consumption during quarantine. Drinking severity indices of the group who increased their
drinking during the quarantine period were signicantly positively related to depression severity, anxiety severity and positive
urgency (impulsivity subset).
8SallieSN, etal. BMJ Open 2020;10:e044276. doi:10.1136/bmjopen-2020-044276
Open access
more likely than males to consume alcohol in order to
cope with stress.25
COVID-19 specific stress factors appear to influence
drinking behaviours controlling for other confounding
variables. Being deemed an essential worker and having
children was associated with a greater increase in drinking
behaviours during quarantine. Importantly, although
having children was associated with an increase in alcohol
use, depression and anxiety scores were lower than in
those without children. This suggests the additional
burden of childcare and home schooling contributed to
the tendency towards drinking- possibly in the context of
stress relief- and was not mediated by greater depression
or anxiety symptoms. The presence of children may also
be protective against depressive and anxiety symptoms
during lockdown. Having children may mitigate against
loneliness that has been highlighted as a major issue
during the isolation of lockdown.26 A subset of the essen-
tial worker category–healthcare workers responsible for
taking care of individuals with COVID-19—was associated
with greater severity of problem drinking behaviours.
Thus, the specific impact of lockdown on the necessity for
essential workers and the impact of the burden of home
schooling and childcare on parents appears to enhance
drinking behaviours independently of an impact on
psychiatric symptomatology.
As expected, having a personal relationship with
someone who had become severely ill or died due to
COVID-19 was associated with a greater increase in severity
of problem drinking behaviours. Going outdoors more
frequently for work, exercise, or essential duties during
lockdown was similarly associated with greater severity of
alcohol use, as well as depressive and anxiety symptoms.
The reasons behind the need to go outdoors complicate
the interpretation, as it might be confounded by being an
essential worker, but would also allow for greater access to
the purchase of alcohol. Living with others but having a
poor quality of relationship was unexpectedly associated
with lower drinking severity but with greater depressive
and anxiety symptoms. Living alone was not associated
with any changes in drinking behaviours but was associ-
ated with greater depressive symptomatology. These find-
ings might support the role of drinking in the context
of social interactions and further highlight the impor-
tance of socialisation during lockdown, the role of lone-
liness, and its impact on mental health.26 Importantly,
those residing in the UK–unlike those in the USA and
Canada—displayed an increase in weekly alcohol units
consumed during quarantine, consistent with the WHO
Global Status Report on Alcohol and Health (2018),
which shows that total alcohol consumed per capita is
higher in the UK than in the USA or Canada.27
We further observed a relationship between the current
severity of drinking behaviours and psychiatric symptoms
such as depression, anxiety, and positive urgency. These
relationships were driven particularly by the group that
increased their drinking during quarantine. That both
negative and positive emotionality factors are associated
with increased drinking behaviours is in keeping with
the multiple paths towards problematic alcohol use. The
effects of depression and anxiety on alcohol consump-
tion in both AUD and non- AUD drinkers are well docu-
mented,28–31 and related to mechanistic theories of
negative emotionality, which suggest that individuals
may increase their alcohol consumption in stressful
contexts to cope with aversive emotional states.32 Posi-
tive emotional factors also appear to play a role in the
association with positive urgency, a subtype of impulsivity
characterised by the propensity to engage in disinhibited
behaviours- including alcohol consumption- when experi-
encing an intensified hedonic or excited state.31 Positive
affect- based impulsivity may reflect a heightened reward
sensitivity associated with problem drinking behaviours.33
Limitations and future directions
This study is not without limitations. HabiT is a cross-
sectional, retrospective survey and hence potentially
limited by recall and misclassification biases as well
as lack of longitudinal follow- up. Because retrospec-
tive reporting involves issues with memory, possible
Dunning- Kruger effects, and selection bias, the
reader should be cautious in drawing causal interpre-
tations from the current data. Because the aim of the
HabiT study was to investigate changes in amount and
severity of drinking behaviour in a large, wider popu-
lation, we issued the survey internationally and during
a later period of enforced isolation. Thus, the possi-
bility cannot be overlooked that subjects were within
varying phases of lockdown characterised by differen-
tial restrictions during the time of testing, which may
have influenced our current results. Future studies
may consider data analysis by country, level of lock-
down, or amount and severity of localised COVID-19
cases. Also, approximately half of the individuals who
began the survey did not complete it. This may be due
to the length of the survey (ie, 8–10 min). Prospective
studies using an online survey design should further
condense questionnaires and/or offer subjects mone-
tary incentives obtained on survey completion in
order to attenuate dropout and non- response bias.
The current HabiT survey only assessed the acute
effects of COVID-19 isolation measures on changes
in drinking behaviours in comparison to the prequar-
antine period. Hence, follow- up studies should be
employed during the immediate postquarantine
period to investigate the possible protracted effects of
COVID-19 isolation on drinking behaviours. Further-
more, whether the sampling adequately reflects the
population distribution in the form of sampling bias
may be an issue with online questionnaires and may
under- represent those who do not have smartphones
or access to the internet,34 have limited facility with
online questionnaires (eg, older individuals),34 were
otherwise engaged (eg, caring for an ill individual or
children), or are more severely ill with substance use
or other mental health disorders. Thus, our ability to
9
SallieSN, etal. BMJ Open 2020;10:e044276. doi:10.1136/bmjopen-2020-044276
Open access
generalise our current findings to the wider popula-
tion is limited. Other methods (eg, phone surveys)
are recommended to reach populations under-
represented by online surveys.35 As few respondents
reported a previous history of alcohol problems rela-
tive to the expected prevalence rates, the reporting is
likely either a function of sampling bias, limited will-
ingness to reveal such a history in an online survey, or
marked changes in alcohol use particularly if relapse
occurs. This limits our capacity to assess the change in
drinking behaviours in those with a history of alcohol
problems. Further studies focusing specifically on
the newly abstinent or those with a history of alcohol
problems are indicated.
CONCLUSION
Although alcohol drinking behaviours appeared to
decrease overall during lockdown, we emphasise that
specific groups may be at higher risk for developing
problematic alcohol use. In particular, factors associ-
ated with an increase in alcohol use include older indi-
viduals, essential workers, parents with children, those
with a personal relationship with someone severely ill
from COVID-19, and those with higher depression,
anxiety, or positive urgency impulsivity. Furthermore,
unlike residents from the USA and Canada, those in
the UK increased their weekly alcohol intake during
the quarantine period. We emphasise that those with
a previous history of alcohol misuse or a family history
of AUD were not the specific focus of this study, and
may represent a high risk group that requires further
investigation. Alcohol can be used in brief, moderate
amounts in a healthy, non- pathological manner
related to socialisation and stress relief. However, a
subgroup of these individuals may still be at higher
risk for longer term issues with alcohol misuse. The
lockdown resulted in a unique set of stressors that
in some cases may persist (eg, childcare, grieving,
prolonged depression or anxiety related to the lock-
down) and might again re- emerge with the imposi-
tion of localised lockdowns or further lockdowns in
the context of a second or third wave. Further studies
on the longitudinal impact and persistence of these
behaviours are critical. Our findings highlight a need
for identifying those at greater risk for alcohol misuse
to aim for greater support services and proactively
target mental health issues associated with problem
drinking behaviours such as depression or anxiety.
Contributors SNS created the Habit Tracker (HabiT) survey, collaborated with VR
in analysing the collected data, and drafted and edited the manuscript. VR coded
and analysed the data. HB- J collaborated with VV in conceptualising the study. VV
conceptualised the study, gave crucial guidance in creating the HabiT survey and
edited the manuscript.
Funding This research was registered as a no- cost project, under grant number
G107438. VV is supported by a MRC Senior Clinical Fellowship (MR/P008747/1).
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval HabiT was approved by the Cambridge Psychology Research
Ethics Committee.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All participant data used in this research are
deidentied. Participant data and MATLAB statistical code used for analysis are
available on reasonable request from corresponding author, Samantha N Sallie, at
habittstudy2020@ gmail. com.
Supplemental material This content has been supplied by the author(s). It has
not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
peer- reviewed. Any opinions or recommendations discussed are solely those
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
of the translations (including but not limited to local regulations, clinical guidelines,
terminology, drug names and drug dosages), and is not responsible for any error
and/or omissions arising from translation and adaptation or otherwise.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits
others to copy, redistribute, remix, transform and build upon this work for any
purpose, provided the original work is properly cited, a link to the licence is given,
and indication of whether changes were made. See:https:// creativecommons. org/
licenses/ by/ 4. 0/.
ORCID iD
Samantha NSallie http:// orcid. org/ 0000- 0003- 0161- 3995
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