Alcohol consumption during the COVID-19 pandemic: a necessary reflection for confronting the situation Consumo de álcool durante a pandemia da COVID-19: uma reflexão necessária para o enfrentamento da situação Consumo de alcohol durante la pandemia de la COVID-19: una reflexión necesaria para enfrentar la situación

Facing the COVID-19 pandemic has so far required implementing non-pharmacological Public Health interventions, especially those aimed at physical distancing 1,2. Affected countries adopted different strategies – from the isolation of cases and contact tracing to lockdown, including the temporary closure of bars, restaurants, nightclubs, among others 3. Due to the restricted operation of such establishments, alcohol consumption, which took place in public spaces, became private, with home becoming the place of choice for this behavior. It is worth noting that the consumption of alcoholic beverages is linked to more than 230 diseases and illnesses, as a result from the effects of ethanol, which is a psychoactive, reinforcing, carcinogenic, immunosuppressive, toxic to cells and tissues and teratogenic substance. It is one of the main causes of preventable mortality in the world and responsible for 3 million deaths each year 4,5,6. The World Health Organization (WHO) considers that there is no safe limit for alcohol consumption and that health damage increases with the amount consumed 4,7. In particular, excessive consumption weakens the immune system and decreases the body’s ability to fight bacterial 8 and viral 9 infectious diseases, such as COVID-19, which can increase the risk of infection during the pandemic. Nevertheless, at the beginning of the pandemic, fake news circulated that drinking alcohol would provide some protection against COVID-19 or kill the coronavirus. As a result, more than 700 people died in Iran after drinking alcohol of unknown origin and contaminated with methanol 10. Similar cases have been reported in Costa Rica and the Dominican Republic. To protect the population from this type of misinformation, the WHO released a report warning that alcohol consumption absolutely does not protect against COVID-19; on the contrary, it can harm the immune response 5. Several hypotheses have been raised seeking to discuss the effect of alcohol on mental health during the pandemic 7. All of them highlight that alcohol is a substance that depresses the central nervous system, and its consumption is strongly associated with other mental disorders. During isolation, this association is enhanced and can trigger or exacerbate depressive and anxious episodes, as well as increase the risk of suicide. With the increase in regular use and the amount of alcohol consumed, in the long run, there will be increased tolerance and dependence. The potential public health effects of long-term isolation on alcohol consumption and misuse are still unknown,6 but studies conducted in several countries indicated a higher incidence of anxiety, depression and alcohol consumption, in addition to lower mental well-being during isolation in response to the epidemic 11,12,13,14. 1 Instituto de Pesquisa Econômica Aplicada, Brasília, Brasil. 2 Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brasil.

Cad. Saúde Pública 2020; 36(10):e00124520 Among young people and adolescents, such effects may take a few years to be identified. The consequences for children living with adults who started drinking at home are yet unknown, but the conjecture is that this exacerbated exposure is associated with early initiation, by easy access, perception of social acceptance of consumption 15 and the experience of more episodes of domestic violence 16 . It is worth mentioning that, among adolescents, parental styles are associated with the pattern of alcohol consumption and it is assumed that staying at home under parental supervision can lead to decreased consumption, particularly when parents adopt the authoritarian style, that is, offering more monitoring and responsiveness to adolescents' needs 17 . On the other hand, we must consider that parents who increased their alcohol consumption at home during quarantine, drinking more frequently or in greater quantity, contribute to changing their children's normative beliefs, who can interpret drinking as routine. In practice, this change in normative beliefs is associated with more harmful patterns of alcohol use in adolescence and should be avoided 18,19 . Moreover, we must consider that some parents who increased their alcohol consumption may have understood that it was time to "teach their children to drink", contradicting all scientific knowledge about preventing alcohol use by minors 20 .
The search for alcohol use in stressful situations occurs, mistakenly, by its depressor effect of the central nervous system, which, at first, seems to relax those who consumed it. On the other hand, this same pharmacological effect is responsible for several types of accidents. Falls, burns and shocks, as well as traffic accidents, can cause injuries that sometimes require emergency care 21 . In the context of the pandemic, injury accidents that require care, in addition to overloading services, can increase the risk of COVID-19 transmission in the health services themselves.
Another negative effect of alcohol consumption, enhanced by physical distancing, is domestic and family violence, whose main victims are women and children 22,23 . In Brazil, between March 1st-16th and 17th-25th 2020, the number of complaints registered by the Disque 100 and Ligue 180 hotlines increased 18% 24 . Several states also registered an increase in the number of femicides. In São Paulo, this number, in March 2020, was 46.2% higher than the same month in the previous year, while in Mato Grosso, femicides quintupled 25 . Men are the main perpetrators of domestic and family violence against women, which is exacerbated by alcohol consumption. Survivors, in turn, tend to increase alcohol use to cope with the situation of violence 26 .
Moreover, evidence shows that the risk of alcohol dependence is higher as people are more exposed to natural disasters. A longitudinal study in the United States found that both the number of hurricanes and of stressful events that occurred in the following week were direct predictors of the alcohol doses consumed by the people exposed in the following year 27 . Similar behavior was found after exposure to a terrorist attack 28 , reinforcing evidence that trauma or post-traumatic stress increases alcohol use disorder 29 .
Some studies point to intensified alcohol use in grieving situations 30 . Thus, as COVID-19 emerges as one of the main causes of death, there is additional concern about alcohol consumption patterns during isolation and in the coming years. Considering that the pandemic is an experience of potential impending death and because it resembles the experience of natural traumatic episodes, we can suppose that later alcohol consumption patterns will increase, with implications for associated mortality and morbidity.
At the moment, there has been an increase in alcohol consumption at home, apparently due to isolation, against the evidence on the associated damage. In China, 32% of regular alcohol users reported increased use, and 19% reported a relapse to alcohol abuse during the pandemic 31 . In the United Kingdom, nearly a fifth of survey participants who reported drinking alcohol daily increased the amount consumed during lockdown 32 . In Germany, 34.7% of respondents to an online survey reported that they started drinking more or much more alcohol after lockdown started 33 . In Brazil, the situation is similar. An online survey with 44,062 participants revealed that 18% of the population aged 18 years or older reported increased alcohol use during the pandemic 34 . A survey commissioned by the Brazilian Beverages Association (Abrabe) 35 . in 2019, revealed that 61% of alcohol consumption took place in bars, restaurants, nightclubs and various events. With the closure of these establishments and the ban of mass gatherings, consumption began to take place predominantly in the domestic environment, also encouraged by online events, such as happy hours and parties, which spurred a sales increase of beverages in supermarkets.
Cad. Saúde Pública 2020; 36(10):e00124520 Going to the supermarket is a situation of potential exposure to coronavirus and the risk of contagion can be increased when the person is under the influence of alcohol. The reduced perception of risk resulting from its pharmacological effect 36 may result in decreased adherence to preventive measures among users, including the interruption of isolation to purchase and consume alcoholic beverages, non-adherence to hygiene measures and the incorrect use of masks.
In Brazil, regulation of sale of alcoholic beverages in supermarkets is almost non-existent. Such locations allow displaying drinks in areas of high visibility, including near the cashiers, carrying out promotion sales and selling packages with multiple units, without quantity limit, nor restriction of day of the week or time. Moreover, there is ease of purchase on websites and applications, including cool beverages, without contact with the buyer, as in Australia 37 . In these situations, the actual control of the buyer's age is absent. This scenario exposes the need to reinforce the control of sales to minors, both on the Internet and at physical points of sale. The availability of beverages in supermarkets and for home delivery facilitates consumption, which is hardly in line with the recommendations of WHO's SAFER strategy 38  Some municipalities in Brazil, as well as the states of Piauí and Paraná, have enacted temporary prohibition aimed at reinforcing isolation measures. Although they can be considered radical, such measures reinforce the message that alcohol consumption is not essential to the population and that the licensing system for selling alcoholic beverages should be revised, so that the State undertake greater responsibility for protecting people from the harm associated with domestic consumption, both in the context of the pandemic and in the future 41,42 .
Including confronting alcohol consumption as part of the response to COVID-19 is justified because the behavior is a risk factor for the infection itself, whether by a biological mechanism 43 , or by the ability to gather crowds in leisure events 44 and increase hospital demand due to trauma resulting from alcohol intoxication. Given this context, it is urgent that governments and civil entities in the health area adopt strategies to guide the population on the harm associated with alcohol consumption, disseminating WHO's position. Moreover, the regulation on the use and marketing of alcoholic beverages should be reinforced, in line with the interests of Public Health and the SAFER strategy. Such actions should be complemented by the maintenance and strengthening of support services for users of alcohol and other drugs.
Cad. Saúde Pública 2020; 36(10):e00124520 Contributors L. P. Garcia and Z. M. Sanchez participated in the design of the article, the literature review, the writing, and the final review. The authors agree with the version submitted for publication and assume responsibility for the integrity of the article.