Lockdown and licensed premises: COVID-19 lessons for alcohol policy
The COVID-19 pandemic necessitated unprecedented changes in alcohol availability, including closures, curfews and restrictions. The researchers draw on new data from three UK studies exploring these issues to identify implications for premises licensing and wider policy.
- Semi-structured interviews (n = 17) with licensing stakeholders in Scotland and England reporting how COVID-19 has reshaped local licensing and alcohol-related harms;
- Semi-structured interviews (n = 15) with ambulance clinicians reporting experiences with alcohol during the pandemic; and
- Descriptive and time series analyses of alcohol-related ambulance callouts in Scotland before and during the first UK lockdown (1 January 2019 to 30 June 2020).
COVID-19 restrictions (closures, curfews) affected on-trade premises only and licensing stakeholders highlighted the relaxation of some laws (e.g. on takeaway alcohol) and a rise in home alcohol use as having long-term risks for public health.
Ambulance clinicians described a welcome break from pre-pandemic mass public intoxication and huge reductions in alcohol-related callouts at night-time. They also highlighted potential long-term risks of increased home alcohol consumption.
The national lockdown was associated with an absolute fall of 2.14 percentage points in alcohol-related callouts as a percentage of total callouts, followed by a daily increase of +0.03%.
Discussion and Conclusions
COVID-19 gave rise to both restrictions on premises and relaxations of licensing, with initial reductions in alcohol-related ambulance callouts, a rise in home alcohol consumption and diverse impacts on businesses.
Policies which may protect on-trade businesses, while reshaping the night-time economy away from alcohol-related harms, could offer a ‘win–win’ for policymakers and health advocates.
Added value of the study
In this study, the researcher do two things:
- review primary qualitative data from interviews which took place during the pandemic for two separate studies not originally focused on COVID-19; and
- analyse secondary data on alcohol-related ambulance call-outs during the first UK national lockdown.
Using this data, the researchers seek to inform discussions of the following three questions:
- How might the pandemic have reshaped regulation of alcohol sales via the local premises licensing system in England and Scotland?
- What are ambulance clinicians’ experiences and views of alcohol-related ambulance callouts during the pandemic?
- How did alcohol-related ambulance callouts in Scotland change in volume and timing during the first UK national lockdown compared to non-alcohol callouts?
To date, the impact of COVID-19 on alcohol-related ambulance callouts has not been reported. This study provides first evidence.
This study can contribute to an understanding of the potential implications of changes in the alcohol regulatory environment and related behaviours during the pandemic, for public health and emergency service utilisation in the short and medium term.
Alcohol and COVID-19 in Britain
The COVID-19 pandemic necessitated unprecedented changes in alcohol availability with closures, curfews and operating restrictions in many countries. In the UK, alcohol retailers were designated as essential services and permitted to trade throughout the pandemic. Shops and online retailers, including supermarkets, are likely to have benefitted significantly, where they stayed open while bars were closed.
Other pandemic control measures also have implications for where, when and how much alcohol is consumed.
- It may be ‘easier’ to consume alcohol where people work more from home with less need to drive and lower visibility.
- Greater consumption or alcohol problems may also be driven by increased caring responsibilities, stress levels, bereavement, isolation, job insecurity and poverty with reduced access to services and social supports, particularly affecting women, ethnic minority and economically disadvantaged groups.
In the UK, overall alcohol sales fell during the first national lockdown (driven by falls in on-trade sales, especially beer, while premises were closed), but then largely recovered. UK survey data from early in the pandemic indicates that high-risk alcohol use may have increased, more so in women and disadvantaged groups, while affluent groups were more likely to report attempts to cut down their consumption, raising concerns about exacerbations of existing inequalities.
Much UK public discourse has centred on hardships for hospitality businesses arising from public health measures with surprisingly little discussion of reduced pressures on emergency services.
The burden of alcohol on health services is well documented, including recent work estimating that 16.2% of all ambulance call-outs in Scotland are alcohol-related. Shifts to home alcohol consumption may lead to increases in consumption, gender-based violence or risks for children, including neglect or normalizing of parental alcohol use.
Alcohol, COVID-19 and health system burden international evidence
Alongside changes in alcohol consumption, a general decline in healthcare utilisation for non-COVID-19 issues was observed early in the pandemic, with decreases across wide ranging conditions.
- A US study found a 31% decrease in ambulance responses for April 2020 compared to the previous year.
- Fear of infection and a desire to avoid burdening health services may explain these falls; though health behaviours, including alcohol consumption may also be a factor.
- In Canada, alcohol-related visits at accident and emergency departments decreased at the beginning of the pandemic but to a lesser extent than other visits.
- In New York City, during the initial COVID-19 peak in spring 2020, hospital visits for alcohol withdrawal increased while those for alcohol use decreased.
International examples show how governments institute restrictions on alcohol explicitly to reduce the burden on front-line health services.
Findings for building back better with evidence-based alcohol policy
The findings of this original study suggest at least four broad impacts with implications for alcohol harms and policy:
- relaxation of some aspects of licensing policy,
- significantly fewer alcohol-related ambulance callouts initially followed by a resurgence,
- perceived increases in home alcohol consumption, and
- diverse impacts on businesses.
Implications for licensing policy
First, licensing stakeholders highlighted that restrictions on capacity and sales of alcohol indoors had led to an increase in applications from bars/pubs to serve alcohol in spaces outdoors and an increase in premises permitted to offer home delivery. When physical distancing remains a requirement, meaning reduced customer numbers indoors, extra outdoor space is unlikely to increase overall availability of alcohol, but it may increase risks of public disturbance via noise or other antisocial behaviour.
It may be difficult to reverse outdoor licences granted during the pandemic, even when physical distancing is no longer required, suggesting a significant increase in overall capacity in those venues.
A shift towards outdoor alcohol use renders alcohol consumption (and any related drunkenness) more visible, including to children and people in recovery from alcohol problems who may be passing by.
The pandemic may have contributed to expansions in availability as licence applications received less public health scrutiny, but may have had some benefits in building relationships between stakeholders seen as important for facilitating successful public health engagement in licensing.
Reductions in alcohol burden on ambulance services during lockdown
Second, qualitative data from the Scottish Ambulance Service indicate that the pandemic period, during which premises were either closed completely or not open late at night, was associated with a substantial reduction in demand for ambulances arising from alcohol consumption.
The quantitative data shows that total alcohol-related callouts fell even more than overall ambulance call-outs in the first months of lockdown, but rebounded after 2 months.
The reduction was particularly acute at weekend night-times, and call-outs at these times remained lower than usual through to the third month after lockdown.
Reductions in call-outs were linked to the closure of licensed premises and the night-time economy (NTE), more than ‘stay at home’ measures introduced at the same time, even though these probably reduced socialising in people’s homes.
Exceptionally good weather in May 2020 may have mitigated the latter effect, perhaps explaining a rebound in weekend callouts that month even with premises still closed; that disappeared in June 2020. Ambulance clinicians reported clearly that, in normal times, many ambulance callouts are associated with people in or around pubs/bars/clubs in the NTE and that these were greatly reduced.
The views expressed by paramedics are powerful and give pause for thought about whether business recovery post-COVID has to mean a return to the ‘mass intoxication’ and ‘battlefield environment’ on city streets, which they described. As premises re-open and especially in Scotland where the ambulance service is under intense pressure in 2021, authorities should be looking to avoid this.
There is surely an opportunity for politicians and clinicians to show leadership in pushing for better alcohol policies that protect frontline services. Effective multi-faceted interventions already exist to reduce alcohol intoxication and violence and could be more widely and consistently deployed, although are unlikely alone to be transformative.
Transforming the night-time economy to rely less on alcohol?
It is timely to consider whether economic prosperity in the NTE must rely on alcohol and whether there is a third way or ‘sweet spot’ approach via policies which transform and build the NTE to prioritise other forms of entertainment, food, music or more family-friendly environments.
The nature of such policies and their feasibility and acceptability to communities [48, 49] and trade stakeholders, plus their likely and actual effectiveness in balancing prosperity and reducing harms, requires further consideration and research.
Strategic planning policies at local authority level, availability and promotion of no/very low alcohol products and ‘place-shaping’ in the licensing system, through which premises perceived as lower risk (restaurants, arts venues) are prioritised in licensing policy over others with a strong alcohol focus may all have a role to play.
Further work is underway to collate and assess the feasibility and acceptability of innovative initiatives in this space to inform policymaking.
Increased home alcohol use during the pandemic
The third issue highlighted by both licensing stakeholders and ambulance clinicians, is that the pandemic shifted alcohol sales and alcohol consumption from the on- to off-trade, exacerbating existing trends.
Reportedly driven by increases in home delivery of alcohol coupled with closures of premises and ‘stay at home’ orders, interviewees’ perceptions of increases in home alcohol consumption are supported by sales and survey data from other sources.
While the proportion of alcohol-related callouts returned to that of pre-lockdown periods shortly after May 2020, callouts were spread throughout the week; while the incidence at weekends remained persistently lower, especially at night. This suggests that after the first 2 months of lockdown, ambulance services may have already been seeing an increase in demand arising from home alcohol use. It is difficult to know what types of call-outs would have generated these trends, however it could have arisen from a rise in outdoor get-togethers/house parties, increased consumption in groups vulnerable to liver failure or acute harms or greater incidence of alcohol withdrawal.
Research in Cardiff, Wales found a significant decrease in emergency department visits by people injured by violence, driven by a large reduction in visits due to violence outside the home. No significant increase in emergency department visits resulting from violence at home was noted. For injury outside the home, significant decreases were found in emergency department visits by female individuals younger than 18 years and by male individuals in all age groups, those injured with weapons and those in which the perpetrator was a stranger, acquaintance or security officer.
The relationship between emergency service utilisation and alcohol during the pandemic is likely to be highly context specific. It will also hugely depend on the pattern of restrictions in place as illustrated by findings from North America and evidence from South Africa finding reduced emergency attendances during total and partial alcohol sales bans.
Overall implications of the pandemic for alcohol policy
Overall, it seems likely that the closure of licensed premises led to net reductions in the burden of alcohol-related harm on emergency services, even with a shift to home alcohol consumption, but that this was relatively short-lived.
Total closures or prohibitions are neither practical nor desirable in a liberal society and the study’s findings support the suggestions of others that an associated shift to home alcohol consumption may result in mid- and long-term harms.
In the longer term, the cheaper price of alcohol bought from off-licence premises enables consumption of greater amounts of alcohol at home, raising the risk of conditions (cancer, hypertension, etc.) that would not arise during the follow-up period in this study, nor be easily identified as alcohol-related in ambulance/emergency department data. Interventions to raise the price of off-trade alcohol (such as increases in or the introduction of minimum unit pricing) are likely the most effective available option to reduce shop-bought alcohol consumption.
Minimum unit pricing can also reduce the price differential between on and off trade premises, which may encourage people to consume alcohol in licensed premises; it may therefore support the hospitality sector, while protecting health.
Alcohol use (or alcohol intoxication) at home is more visible to children than alcohol use by adults in bars/pubs where children are not permitted. Furthermore, for vulnerable subgroups, home alcohol consumption may be associated with exacerbations of domestic violence, isolation and alcohol dependence.
The rise in home alcohol use illustrates a blind spot in licensing policy: systems largely designed to control ‘outlet density’ and maintain public order, have failed to adapt to address online sales or hidden harms associated with home alcohol use.
There is now an opportunity to consider better regulation of online sales/home delivery of alcohol, alongside pricing interventions as above, which would protect public health without impacting on (or perhaps supporting) the recovery of hospitality sectors post-COVID.
How the pandemic may be reshaping the on-trade alcohol sector
A final issue highlighted by the study findings is that the pandemic is likely to have longer term impacts on the alcohol sector. Smaller premises and nightclubs, even if permitted to open, have been particularly affected, as distancing requirements were often impractical. Independently-owned businesses may be less likely to have the financial reserves to survive the hardship of lockdowns, despite government support and are reportedly being bought up by large pub companies. Such chains may have greater lobbying power, which policymakers and other stakeholders in licensing will need to be equipped to handle.
Furthermore, several larger pub companies also produce and supply alcohol for sale in shops and may therefore oppose measures to reduce home alcohol use, even if they might benefit bars. Independent bar owners and policy stakeholders should be mindful of these conflicting interests in trade associations that represent both on- and off-trade interests.