Did COVID-19-Related Alcohol Sales Restrictions Reduce Alcohol Consumption? Findings from a National Online Survey in South Africa

Background: South Africa has a high prevalence of heavy episodic drinking (HED). Due to the high levels of alcohol misuse and violence, public hospital intensive care units were often overrun during the COVID-19 pandemic. This research investigated alcohol intake behaviour change during differing levels of lockdown restrictions, which included bans on alcohol sales. Methods: A self-reported Facebook survey ran from July to November 2020. The questions included socio-demographics, income, alcohol intake, purchasing behaviour, and reasoning. Chi-square tests/Fisher’s exact test for categorical data, Student’s t-test for normal continuous data, and the Mann–Whitney U test for non-normal data were applied. Multiple logistic regression was run for HED versus moderate drinkers. Results: A total of 798 participants took part in the survey, of which 68.4% were female. Nearly 50% of participants fell into the HED category and the majority bought alcohol illegally during restrictions. HED respondents who drank more alcohol than usual during restrictions reported that they felt stressed, needed to relax, and were bored. Conclusions: Policies intended to increase the pricing of alcohol may have the potential to reduce alcohol intake. Reducing stress and anxiety may be key to curtailing HED during emergency situations.


Introduction
In 2020, the World Health Organization (WHO) declared the novel 2019-nCoV (coronavirus disease 2019) a global pandemic [1], with over 256 million infections and more than 5 million deaths worldwide to date, and numbers are still increasing [2].
In South Africa (SA), this led to the declaration of a national state of disaster by the government [3] and subsequent restrictions on various activities such as outdoor exercise, dog-walking, travel, and purchasing alcohol and cigarettes. These restrictions were imposed by amending the Disaster Management Act [4].
Widespread uncertainty and fear of the disease itself, in addition to secondary consequences such as home confinement and various restrictions, have had a severe impact on mental health globally [5]. Nearly 50% of South Africans reported symptoms of anxiety and depression in a study conducted from 20 to 31 May 2020 [6].
In some countries, alcohol was classified as an essential item, while in SA, the sale and transport of alcohol were banned (as gazetted in the Disaster Management Act) for a  5 Physical distancing only required. 6 Life as normal. * Heavy episodic drinking is when a person consumes more than 6 drinks per occasion monthly or more frequently.

Statistics
Data cleaning and checking were executed in Microsoft Excel (Microsoft corporation, Washington, USA) [20] prior to being imported into SPSS (IBM corporation, New York, USA) [21] and STATA (STATA corporation, Texas, USA) [22] software. Numerical data were checked for normality using the Shapiro-Wilk test. Normal data are reported as mean (standard deviation) and non-normal data as median (interquartile range), while categorical data are reported as frequencies and percentages. Data were analysed in an iterative way by first performing explorative analyses, then searching for associations using Chi-square tests/Fisher's exact test for categorical data, Student's t-test for normal data, and the Mann-Whitney U test for non-normal data. After identifying variables that were significantly associated with the dependent binary variable of HED and moderate drinking, these variables were entered to compile a standard multiple logistic regression in STATA [22].
The variables that were entered into the model to calculate the adjusted odds ratio (AOR) were sex, age, change in monthly net household income since the COVID-19 pandemic restrictions, aged 70+ or serious medical condition or immunocompromised, frequency of alcohol consumption, illegal alcohol purchasing, first time buying alcohol illegally, restrictions made it harder to cut down on drinking, and alcohol makes social/physical distancing more difficult. Multicollinearity was assessed by examining correlations between predictors. No two predictors had a correlation of more than 0.5. Model fit was checked using an adaptation of Hosmer Lemeshow's goodness of fit test, and all models indicated appropriate fit. p-values less than 0.05 were considered statistically significant. Participants with missing data, n = 569 or 41.2%, were more likely to be of coloured ethnicity (Fisher's exact, 8.742, p = 0.026). However, gender, age, province, and change in income did not differ significantly for missing data.

Ethical Considerations
Participants were anonymized and responses were stored in secure firewalled facilities that were password protected. Access was only given to research team members. Information was given upfront regarding alcohol addiction help lines and the contact details of researchers for more information. Participants were assured that participation was voluntary and were asked to indicate their agreement to participate by choosing 'agree' or 'not agree' to participate, which were used to indicate signatory agreement of the informed consent sheets. This research was given ethical approval by the South African Medical Research Council (ref: EC017-6/2020) and the University of the Western Cape Biomedical Research Ethics Council (ref: BM21/5/11).

Results
The final survey comprised 798 people (68.4% female). The majority of participants were between the ages of 55 and 64 (29.3%). A significantly younger cohort of females between 18 and 54 years of age completed the survey at a rate of 55% compared to males in this age group at 48% (p = 0.028; Chi-square test) ( Table 2). The highest frequency of participants reported to be of white ethnicity, at 83%, and residing in Gauteng (40%) or the Western Cape (22%), and 65% of respondents reported a decrease in income during the pandemic.  The majority of participants reported that they did not suffer from any serious underlying medical conditions or were immunocompromised at the time of completing the survey. A significantly higher proportion of females than males completed the survey during stricter pandemic restrictions (p = 0.018). However, the majority of participants completed the survey during moderate pandemic restrictions, when people were required to stay at home, were allowed to interact with a few people outside of their household, some businesses and schools were open but public gatherings were banned, and physical distancing was required.
The majority of respondents reported to be alcohol consumers at 88.7%. In terms of drinking patterns (Table 3), males had a significantly higher frequency of daily alcohol consumption, while females were more likely to consume alcohol on a weekly or monthly basis (p = 0.008). A significantly higher frequency of males reported to binge drink on a daily and weekly basis (69.8% versus 51% for females) and more than 61.4% of males were classified as heavy episodic drinkers, compared to females at 42.7%.
Significantly more males reported to have purchased alcohol illegally during the alcohol sales restrictions, while females who did buy alcohol illegally were significantly more likely to have done so for the first time (p = 0.039 and p = 0.002, respectively). When asked whether COVID-19 restrictions made it harder for participants who were trying to cut down on their drinking, significantly more females said that the restrictions made it harder to cut down (p = 0.031). The majority of participants, however, did not think that alcohol made social or physical distancing more difficult.
There was a significantly higher proportion of males in the heavy episodic drinking (HED) group compared to the moderate drinking group (Table 4), while there were significantly more females in the moderate drinking group. The HED group was significantly younger, with 66% of them below the age of 55.   There was no difference for the ethnicities, provinces, or restriction levels between the HED and moderate drinking groups.
Significantly more people in the HED group reported a reduction in their income after COVID-19 restrictions were introduced, purchased alcohol illegally, and reported that the pandemic restrictions made it more difficult for them to cut down on their alcohol consumption.
Moderate drinkers were significantly more likely to be older or have underlying medical conditions, reported that they consumed alcohol only monthly, that alcohol does make social distancing more difficult, and that if they had bought alcohol illegally, it was for the first time.
The HED group reported a significantly higher frequency of consuming more alcohol than usual than the moderate drinking group (p < 0.001) during both increased and decreased lockdown restrictions (Figure 1a,b). Similar frequencies were reported by heavy episodic drinkers and moderate drinkers of consuming the same amount of alcohol as usual during both increased and decreased restrictions. A significantly higher frequency of the moderate drinkers than drinkers in the HED group reported consuming less alcohol than usual during both increased and decreased lockdown restrictions. Reasons given for consuming more alcohol as the restrictions increased and decreased that were significantly more frequent for the HED group than for the moderate drinking group were, in descending order, feeling stressed, helping them to relax, feeling bored, having more time to consume alcohol with their household, and not needing to wake up for work/study (Figures 2 and 3). Having more online social occasions was found to have a significantly higher frequency as the restrictions increased for HED only ( Figure  2). Celebrating the lifting of restrictions and being able to see and drink with their friends was found to have a significantly higher frequency as the restrictions decreased for HED only (Figure 3).  Reasons given for consuming more alcohol as the restrictions increased and decreased that were significantly more frequent for the HED group than for the moderate drinking group were, in descending order, feeling stressed, helping them to relax, feeling bored, having more time to consume alcohol with their household, and not needing to wake up for work/study (Figures 2 and 3). Having more online social occasions was found to have a significantly higher frequency as the restrictions increased for HED only (Figure 2). Celebrating the lifting of restrictions and being able to see and drink with their friends was found to have a significantly higher frequency as the restrictions decreased for HED only (Figure 3). drinking group were, in descending order, feeling stressed, helping them to relax, feeling bored, having more time to consume alcohol with their household, and not needing to wake up for work/study (Figures 2 and 3). Having more online social occasions was found to have a significantly higher frequency as the restrictions increased for HED only ( Figure  2). Celebrating the lifting of restrictions and being able to see and drink with their friends was found to have a significantly higher frequency as the restrictions decreased for HED only (Figure 3). 20    Reasons given for consuming less alcohol as restrictions increased and decreased that were significantly more frequent for the moderate drinking group than for the HED group were that 'it was more difficult to get alcohol while restrictions were placed on going out and while the shops were closed' and that they had 'not been able to socialise or go out or visit a pub' (Figure 4a,b). Feeling that the restriction period was a good time to reduce how much they drank was found to have a significantly higher frequency as the restrictions increased for moderate drinkers only.   Reasons given for consuming less alcohol as restrictions increased and decreased that were significantly more frequent for the moderate drinking group than for the HED group were that 'it was more difficult to get alcohol while restrictions were placed on going out and while the shops were closed' and that they had 'not been able to socialise or go out or visit a pub' (Figure 4a,b). Feeling that the restriction period was a good time to reduce how much they drank was found to have a significantly higher frequency as the restrictions increased for moderate drinkers only.  Multiple logistic regression analysis showed that compared to males, females had significantly lower odds of HED (AOR 0.30; 95% CI 0.13, 0.70; p = 0.006) ( Table 5). Compared to 18-34-year-olds, people who were 65 and older had significantly lower odds of HED (AOR 0.23; 95%CI 0.06-0.91; p = 0.037). Compared to people who consumed alcohol every day or more, those who consumed alcohol 1-4 times per month had significantly lower odds of HED (AOR 0.13; 95%CI 0.03-0.45; p = 0.001).
Furthermore, compared to people who reported purchasing alcohol illegally during the pandemic alcohol sales restrictions, those who did not purchase alcohol illegally had significantly lower odds of HED (AOR 0.20; 95% CI 0.10-0.40; p < 0.001). While not statistically significant, people who stated that it was not difficult to cut down on their alcohol consumption, if they had already been trying to cut down when alcohol restrictions were implemented, also had lower odds of HED (AOR 0.49; 95% CI 0.24-1.00; p = 0.051).  Multiple logistic regression analysis showed that compared to males, females had significantly lower odds of HED (AOR 0.30; 95% CI 0.13, 0.70; p = 0.006) ( Table 5). Compared to 18-34-year-olds, people who were 65 and older had significantly lower odds of HED (AOR 0.23; 95%CI 0.06-0.91; p = 0.037). Compared to people who consumed alcohol every day or more, those who consumed alcohol 1-4 times per month had significantly lower odds of HED (AOR 0.13; 95%CI 0.03-0.45; p = 0.001).  Furthermore, compared to people who reported purchasing alcohol illegally during the pandemic alcohol sales restrictions, those who did not purchase alcohol illegally had significantly lower odds of HED (AOR 0.20; 95% CI 0.10-0.40; p < 0.001). While not statistically significant, people who stated that it was not difficult to cut down on their alcohol consumption, if they had already been trying to cut down when alcohol restrictions were implemented, also had lower odds of HED (AOR 0.49; 95% CI 0.24-1.00; p = 0.051).

Discussion
Lockdown restrictions may impede the efforts of those drinking harmfully to reduce their alcohol consumption. Heavy episodic drinkers reported drinking more alcohol than usual during both increased and decreased restrictions, and reported drinking more alcohol because they felt stressed, felt a need to relax, and felt bored. Significantly fewer people categorised as heavy episodic drinkers thought that the alcohol restrictions were a good incentive to reduce their alcohol intake. Nearly half of those surveyed fell in the HED category and the majority reported buying alcohol illegally during bans on alcohol sales.
This research found that the odds of being classified as a heavy episodic drinker were increased for people younger than 65, males, people who drink more frequently than monthly, people who bought alcohol illegally during the alcohol sales restrictions, and those who reported that reducing drinking was more difficult during the restrictions.
On 27 March 2020, South Africa implemented the first alcohol sales restrictions in response to the COVID-19 pandemic. The first sales ban lasted for about two months, the second and third lasted a month each, and the fourth lasted 28 days. These were the first alcohol sales restrictions in South Africa in 26 years and were implemented without forewarning, preventing the public from buying alcohol in advance. This research aimed to describe changes in drinking patterns and reasons given for these changes, specifically investigating the disparities between heavy episodic drinkers and moderate drinkers.
Our study found that heavy episodic drinkers were prone to consuming more alcohol during restrictions, while moderate drinkers drank the same as usual, or less. Nearly half of the 798 participants who completed the Facebook survey were classified as heavy episodic drinkers, with more than 60% of males and 43% of females falling in the HED category. This is similar to a recent study conducted in Tshwane, South Africa, which reported 53% of adults as being heavy episodic drinkers [23]. These statistics may even be under-representative of the female HED prevalence due to the fact that the cut-off of more than six alcoholic drinks was used for both males and females in this questionnaire, whereas some alcohol intake studies use a cut-off threshold of four standard alcoholic drinks per occasion to identify HED in females [24].
People who were moderate drinkers reported drinking less or similar amounts of alcohol during both increased and decreased lockdown restrictions, while a significantly higher frequency of people with HED reported consuming more alcohol during both increased and decreased lockdown restrictions. This finding is similar to that of Meyers et al. (2021) [25], who found that participants taking part in a study in the Western Cape (n = 61) had one less day of heavy drinking during the alcohol restrictions. However, when they did drink alcohol again, the amount of alcohol consumed increased by an additional three units of alcohol per occasion. We found that 76% of heavy episodic drinkers bought alcohol illegally, showing that the majority of participants in this study found a way to buy alcohol, even though it was illegal.
Research in the United States of America (USA) using a pre-pandemic and continuing pandemic survey showed that people who experienced higher levels of stress due to COVID-19 used alcohol to cope and drank alcohol more frequently [26]. Similarly, our study found that people reported drinking more alcohol due to feeling stressed or anxious, and the reasons for feeling stressed found in other SA studies were the lockdown regulations, alcohol and tobacco sales restrictions, the limitation of people's freedom of movement, loss of jobs, and uncertainty about the future [27].
Reasons given in our study by heavy episodic drinkers for drinking more alcohol during increased restrictions that were significantly more frequent than for moderate drinkers were 'feeling stressed/anxious', 'helps me relax/switch off', and 'I have been bored'. Research conducted two months before our Facebook survey in May of 2020, investigating the impact of the lockdown restrictions on the mental health of people, found that 46% and 47% of participants in the Western Cape achieved the diagnostic threshold for anxiety and depression, respectively (n = 860) [6]. Keeping the results of De Man et al. (2021) [6] and the results found in the Facebook survey in mind, people suffering with HED may be more prone to consuming greater amounts of alcohol during mentally challenging periods such as the emergency lockdown measures of 2020, due to feeling stressed and anxious.
Increased lockdown restrictions were especially relevant to increased stress and anxiety compared to decreased lockdown restrictions, when wanting to relax was mentioned before stress. During decreased restrictions, the reasons heavy episodic drinkers gave for drinking more alcohol that were significantly more frequent than for moderate drinkers were 'wanting to relax/switch off', 'feeling stressed out', 'alcohol shops were now open', and 'celebrating when COVID-19 restrictions were lifted/relaxed'. Interestingly, we see that 'being bored' moved from third to fifth most frequently mentioned.
Reasons given for drinking less alcohol were similar during increased and decreased lockdown restrictions. Significantly more moderate drinkers stated that they drank less alcohol because 'it is more difficult to get alcohol with restrictions on going out and shops being closed' and 'I haven't been able to socialise or go out to the pub'. Importantly, 'money or cost' reasons, the third most frequent, did not differ significantly between HED and moderate drinkers. The Facebook study found that 70% of heavy episodic drinkers experienced a reduction in their income compared to 60% of moderate drinkers. A report by the National Income Dynamics Study (NIDS) and Coronavirus Rapid Mobile Survey 2020 (CRAM) found that there was a 40% decline in active employment as well as a 10% decline in average earnings between February and April of 2020, three months before our Facebook survey [28].
Moderate drinkers stated that the 'restrictions were a good time to reduce alcohol intake' significantly more frequently than the HED group during increased restrictions; it was the fourth most frequent reason given for drinking less.
Our research shows that limiting alcohol sales or imposing alcohol sales restrictions are not proven to be effective in reducing alcohol intake in people who are classified as suffering with HED. However, moderate alcohol consumers may benefit from these restrictions by using them as incentive to reduce their alcohol intake. This finding is similar to research by Meyers et al. (2021) [25]. In our research, we found that 'money or cost' was given as the third most frequent reason why both HED and moderate drinkers consumed less alcohol during the lockdown restrictions, indicating that a minimum unit price on alcohol or an increase in the price of alcohol may be a valid method of reducing the amount of alcohol that people consume [29].
A major limitation of this study was the fact that the majority (83%) of participants who completed the online Facebook survey were of white ethnicity and were older in age, and only two of the nine provinces were well represented, namely Gauteng and the Western Cape. The disparity in participation between ethnicities and provinces could be a result of the unequal accessibility to the Internet and electronic devices, as reported by Statistics South Africa (STATSSA), which showed that 70% of urban households had access to the Internet in 2017, while only 43% of rural households had Internet access [30]. Therefore, the findings are probably not generalisable to all ethnic groups in South Africa or to persons living in all provinces. Additionally, while we had every intention to ensure that participants were over 18, we were not able to verify/guarantee that this was indeed the case.

Conclusions
This research highlighted that people who are classified as heavy episodic drinkers react differently to the effects of emergency situations and concomitant policies that induce anxiety and stress. It was also found that policies intended to increase the pricing of alcohol, such as the WHO strategy of increasing excise taxes and minimum unit pricing, may have the potential to reduce alcohol intake in a time of crisis.
Future research and policy interventions should investigate the effect that social support grants, food security measures, and other policies that improve living conditions may have on anxiety and alcohol intake as broad prevention strategies for chronic conditions related to alcohol. Additionally, support and treatment strategies should be given priority in the case of people with harmful levels of alcohol intake, as suggested by the WHO global strategy and health professionals around the world.  Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
The datasets analysed during the current study are available from the corresponding author on reasonable request.