Increasing alcohol availability during the COVID-19 pandemic could have long-lasting effects on population-level alcohol consumption and, thus, alcohol-related harms. At a time when the healthcare system is already overburdened, preventive measures should be taken to reduce any additional burden from largely avoidable conditions, such as those that are alcohol related.

Introduction

There is no doubt that the call to action by Hartney (2021) deserves the attention of all levels of government and decision makers. However, the claim of an alcohol-use epidemic in Canada being overshadowed by the COVID-19 pandemic may be a bit premature.

Alcohol Use in Canada – Is It Increasing?

In Canada, the per capita (in individuals 15+ years of age) consumption of alcohol (in litres of pure alcohol) has remained relatively stable since the early 2000s. However, heavy episodic drinking (defined as consuming at least 60 grams or more of pure alcohol on at least one occasion in the past 30 days) has been on the rise pre-pandemic (Manthey et al. 2019). How the COVID-19 pandemic has impacted the level of alcohol use in Canada is not yet clear and will only be fully understood once all the alcohol sales statistics and hospitalization data can be triangulated with survey estimates (for triangulation methods, see the articles by Kehoe et al. [2012] and Rehm et al. [2010]).

Currently, data from different survey cycles are not in agreement with one another. For example, the first Statistics Canada survey (2020) indicated that, overall, individuals increased their alcohol use during the pandemic. However, the latest survey reported a more balanced picture – with the percentage of those individuals reporting increased consumption (24%) being almost equal to those reporting decreased consumption (22%) (Statistics Canada 2021). Similarly, alcohol sales data are not fully conclusive. Thus, the overall level of drinking during the pandemic will only be known after data sources are carefully triangulated (Rehm et al. 2021).

While we do not know whether alcohol use has actually increased, there are some facts that are clear. Alcohol retail stores have been designated as an "essential service," and restrictions on home delivery and takeout from restaurants have been loosened in some provinces and territories (Neufeld et al. 2020), thus increasing the availability of alcohol. This increase in off-premise availability is, of course, being balanced in part by restrictions on on-premise drinking. Regardless, greater availability has been shown to impact both heavy alcohol use and alcohol-related harms (Popova et al. 2009). Therefore, the inherent promotion of alcohol use by designating it as essential and an increase in alcohol availability during the pandemic are likely to have both an immediate (via an increase in heavy alcohol use) and sustained (via long-term heavy use leading to an increase in the prevalence of alcohol use disorders in the coming years) impact on alcohol-related harm, especially if such provisions extend beyond the pandemic (Jennison 2004). The impact had will be above and beyond what is already expected with the economic contraction and social restrictions of the pandemic (e.g., Rehm et al. 2020).

Preliminary data from the last Statistics Canada survey, conducted in January 2021, also indicate that those who had increased their alcohol consumption during the pandemic were most likely to report frequent heavy drinking due to boredom, stress and convenience (e.g., access to alcohol) as the most common reasons for increasing their alcohol use (Statistics Canada 2021). These associations have been found not only in Canada but also in a large survey conducted in more than 20 European countries (Manthey et al. 2020). If further research corroborates this finding, it would mean that the pandemic has led to the polarization of drinking behaviour: individuals who experienced boredom and stress increased their alcohol use, while those who did not decreased their use.

Conflict of Interest: Regulators/Retailers of Alcohol and Funders of Healthcare

As Hartney (2021) accurately points out, the roles of provincial and territorial governments as regulators/retailers of alcohol as well as funders of healthcare are in conflict. However, the alternatives – privatized alcohol retail and/or privatized healthcare systems – are a scary thought. Evidence from different provinces in Canada shows that privatized alcohol retail systems, compared to government-owned alcohol retail systems, are associated with negative health outcomes, such as increased alcohol-related deaths (Stockwell et al. 2011; Trolldal 2005). Although not the case everywhere, in recent years there have been changes in several Canadian jurisdictions involving privatization of alcohol retailing. Zalcman and Mann (2007), for example, used a multiple interventions time-series design and demonstrated that three distinct events of alcohol privatization in Alberta were associated with either temporary or permanent increases in the rate of death by suicide during the study period (1976–1999). In the context of the ongoing COVID-19 pandemic, suicide/crisis hotlines are already reporting an unprecedented increase in the number of calls being received (Richmond 2020; Wright 2020). This begs the question: Do we really want to see privatization of alcohol retail now, or ever?

Alternatively, the government could privatize healthcare to eliminate this perceived conflict of interest. However, it is pretty clear that a privatized healthcare system would create inequities in terms of access and quality of care (Angell 2008). For example, in a privatized healthcare system, there is a lack of congruence between need and ability to pay, with those with the greatest medical need being the least able to pay (Angell 2008). In sum, only well-insured patients may benefit from such a system. With respect to alcohol use, it has been shown that high amounts of weekly alcohol consumption and problem drinking are associated with an increased risk of unemployment (Jørgensen et al. 2019). Thus, such individuals would not fare very well in a privatized healthcare system.

Policy-Specific Recommendations

Unsurprisingly, it is well known that the alcohol policy environment can have strong effects on population-level alcohol consumption and, thus, alcohol-related harms (Babor et al. 2010; Burton et al. 2017). One of the mechanisms through which policy can be used to control alcohol use almost instantly is through reduced alcohol availability (i.e., through restricting hours of sale and the number of outlets) (Babor et al. 2010). Policy decisions made during the COVID-19 pandemic can have unintended consequences. For instance, the decision of some provincial/territorial governments to erode restrictions on home delivery and takeout of alcohol from restaurants has increased the availability of alcohol and will likely have an impact on heavy alcohol use and alcohol use disorders in the long run – thus resulting in an increase in alcohol-related harms. At a time when the healthcare system is already overburdened, precautionary measures should be taken to reduce any additional burden due to, in this case, alcohol-attributable conditions. The decision of the federal government to deem alcohol sales an essential service is in no way a "precautionary measure". In addition to population-level interventions, there are effective indicated prevention strategies that target alcohol use, such as increased screening and brief intervention for people with at-risk alcohol consumption (Angus et al. 2014; Kaner et al. 2018).

With this, we encourage provinces and territories to do the following:

• Maintain government monopolies on alcohol sales, and maintain a strong social responsibility mandate.
• Limit the availability of alcohol by reducing hours of sale and the number of alcohol outlets during the ongoing COVID-19 pandemic.
• Reinstate the restrictions on takeout and delivery of alcohol with food in places where such policies were eroded. Although this should be done now, if it is not, it most certainly should be done as soon as the pandemic is over.
• Place an emphasis on screening, brief interventions and referral at the primary care level.

Conclusion

As it stands, the government has unintentionally sent the public the message that alcohol is essential in our lives and has, thus, encouraged its consumption. Given that alcohol use is well established as one of the major risk factors for mortality and burden of disease, we echo the call of Hartney (2021) for governmental support and prioritization of the development and implementation of an evidence-informed framework for both alcohol policy and service delivery. This framework should be developed with the goal of curbing consumption and reducing alcohol-related harms and associated costs during the current public health crisis and beyond.

Commentaire : la pandémie de COVID-19 n'est pas le moment adéquat pour alléger les restrictions sur la disponibilité de l'alcool

Résumé

La consommation d'alcool est bien reconnue dans le monde comme l'un des principaux facteurs de risque pour la charge de morbidité et de mortalité. Bien que l'on ne connaisse pas encore clairement l'impact de la pandémie de COVID-19 sur le niveau général de consommation d'alcool au Canada, nous savons que divers paliers de gouvernement en ont encouragé l'utilisation – soit en le désignant comme essentiel, soit en augmentant sa disponibilité. De telles actions peuvent avoir un impact immédiat et durable sur les méfaits liés à l'alcool au Canada. Nous incitons tous les paliers de gouvernement à soutenir et à prioriser l'élaboration et la mise en œuvre d'un cadre fondé sur les données probantes pour la politique sur l'alcool et pour la prestation de services afin de réduire les méfaits liés à l'alcool pendant la pandémie en cours et après celle-ci.

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