Parental Patterns of Alcohol Consumption During the COVID-19 Pandemic: Scoping Review

Introduction

Background

On March 11, 2020, the World Health Organization (WHO) declared COVID-19 a global pandemic [1]. The restrictive public health measures introduced in many countries contributed to a shadow pandemic of psychological distress [2], which was associated with increased sales and consumption of alcohol [3,4]. Changes in the environments and circumstances in which adults drink can have effects on rates of consumption; lockdown restrictions and sheltering in place led to drinking in the home environment becoming the norm during COVID-19 lockdowns in some places, such as the United Kingdom [5].

In Westernized countries, problematic alcohol use peaks in the third decade of life, a time when many adults are raising young children [6]. The reduction of alcohol consumption is one of the top 10 modifiable risk factors for reducing disease burden, injury, and social problems globally [7,8]. The burden of disease associated with alcohol use is high. A meta-analysis identified alcohol consumption as the seventh leading risk factor for disability and premature death in 2016, and among those aged 15 to 49 years, alcohol consumption accounts for nearly 10% of deaths on a global scale [9].

Parents warrant special attention as a large subsection of the adult population because they are primary caregivers for children. For parents, pandemic stressors (eg, lockdown restrictions, balancing employment while children are at home, and reduced social support) compound the daily stressors of parenting young children [10]. In parallel to the elevated rates of parental depression and anxiety from prepandemic levels [11,12], evidence suggests that the COVID-19 pandemic has increased the consumption of alcohol in parents with young children [13,14]. A meta-analysis of 128 studies (aggregate sample of N=492,235) revealed that nearly a quarter of adults reported increases in alcohol consumption during the COVID-19 pandemic [15]. These changes were moderated by per capita gross domestic product and country. The authors identified that residing with children was associated with increases in alcohol consumption, with consumption increasing with the number of children at home [15]. Moreover, while Acuff et al [15] identified that female participants were more likely to increase their drinking frequency and male participants were more likely to increase their problematic drinking behaviors (eg, binge drinking), it is unclear what proportions of these participants were also caregivers to young children. Currently, a granular and gendered examination of patterns of alcohol consumption in caregiving adults is lacking during the COVID-19 pandemic.

Objectives

The purpose of this scoping review was to investigate broad patterns of parental alcohol consumption during the COVID-19 pandemic, examining the relative changes in the frequency and quantity of alcohol use compared to nonparent adults, prepandemic levels of consumption, or both. In addition to physical health harms related to excessive alcohol consumption [16], parents who consume problematic amounts of alcohol are more likely to have worse mental health and lower emotional availability to children [13]. Poor parental mental health, substance use, and negative parenting practices can have adverse consequences on children’s socioemotional development and mental health [17,18]. The results of this scoping review can assist clinicians working with families in identifying parents at risk for alcohol misuse and engaging them in interventions to reduce consumption. The findings can also inform policy makers regarding the population of parents who may require targeted intervention and education on reducing and managing alcohol consumption in the aftermath of the COVID-19 pandemic.

Methods

Scoping Review Search Strategy

We undertook a scoping review following the methodology outlined by Arksey and O’Malley [19]. We used the Joanna Briggs Institute framework of Population, Concept, and Context (PCC) to create our search terms, with the population being parents (caregiving adults living with children aged <18 years in the same household) and the core concept being alcohol consumption within the context of the COVID-19 pandemic. To capture a wide scope of relevant studies, a librarian team member conducted a systematic search in CINAHL, Ovid MEDLINE, PsycINFO, Web of Science, and Cochrane databases using the specified PCC terms for all articles published after the WHO declaration of the COVID-19 pandemic on March 11, 2020 (Multimedia Appendix 1). The 3 groups of keywords within the PCC framework were joined with the Boolean operator “AND,” which produced 3568 articles for screening in June 2022. Medical Subject Headings and its descriptors were used for CINAHL, Ovid MEDLINE, and PsycINFO. Forward citation searching of articles identified in June 2022 was carried out in May 2023, which further yielded an additional 13 articles.

Inclusion and Exclusion Criteria

After 1430 (40.08%) duplicates were removed from the initial pool of 3568 articles, 2138 (59.92%) articles were screened for eligibility in a 2-round process (Figure 1). In the first round, article titles and abstracts (and text as needed) were reviewed against the PCC framework. We included peer-reviewed empirical studies that were published in English with data collection occurring after the WHO declaration of the COVID-19 pandemic. Nonempirical papers; expert opinions; letters to the editor; preprints; and empirical papers that were published after March 11, 2020, but did not contain alcohol consumption data collected during the COVID-19 pandemic were excluded. Studies that included a comparison of alcohol use between households with children and households without children were included. Reasons for exclusion included study population not being parents with alcohol consumption (eg, adolescent alcohol use) and the lack of explicit data collection on alcohol consumption as a variable. Studies that collected data on adult alcohol consumption during the COVID-19 pandemic but did not differentiate between adults living with children at home and adults not living with children at home were also excluded. Most studies that remained included both parent and nonparent participants (30/40, 75%), while some studies examined parents specifically (10/40, 25%).

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Data Extraction

Data from the articles were extracted into an extraction table derived from Polit and Beck [20]. The table included columns for authors, country of origin, year of publication, research design, sample size, measurement of alcohol use, time frame of data collection, and main findings. Extraction was performed independently by team members (KB and KC) and checked for accuracy (KC). Concerns with data extraction were resolved in consultation with the first author (CO).

Evidence Synthesis

A narrative analysis of the main findings was conducted to identify and compare themes across the included studies. This approach allowed for the evaluation and integration of diverse findings on the trends in parental alcohol consumption during the COVID-19 pandemic.

Results

Overview

Of the 40 studies included in analyses, 36 (90%) were quantitative studies, 2 (5%) were qualitative studies, and 2 (5%) were systematic reviews (Figure 1). Of the 36 quantitative studies, most studies (n=28, 78%) were cross-sectional survey studies, 7 (19%) studies were longitudinal cohort studies, and 1 (3%) was a secondary data analysis of publicly available data (Table 1). The following themes were identified: (1) having children at home was a factor associated with parental patterns of alcohol use, (2) mixed patterns of alcohol consumption among mothers and fathers, and (3) heterogenous linkages between parental patterns of alcohol use and mental health.

Of the 40 included studies, 11 (28%) were also included in the 2 systematic reviews. To prevent undue inflation of support for the themes identified, we cited only the original papers to support specific themes.

Having Children at Home as a Factor Associated With Parental Patterns of Alcohol Use

Many of the studies demonstrated linkages between parental alcohol use and the presence of children at home. Many studies found that, compared to not having children aged <18 years at home, having children at home was a significant predictor for an increase in alcohol consumption during the COVID-19 pandemic in the United States [32-36,38-40], Canada [26,27,29,30], Australia [42-44], Norway [48], Belgium [54], Germany [49], France [55], the United Kingdom [51,53], and Japan [57]. In a global survey study of 1346 adults (half of the sample were from the United Kingdom and United States), having children at home was a significant factor for increases in alcohol consumption, as operationalized by Alcohol Use Disorders Identification Test scores [22]. Participants in a nationally representative US sample of 2-parent households sustained increases in drinking days over the first 4 months of the COVID-19 pandemic, compared with the pre–COVID-19 baseline [38]. These findings are consistent with the conclusion of a higher incidence of increased drinking by adults with children at home compared with adults with no children at home in 2 systematic reviews during the COVID-19 pandemic [4,23]. Moreover, a large-scale global cross-sectional study involving 37,206 participants across 38 countries found households with children were significantly more likely to increase alcohol use compared to households with adults only [21]. An Australian survey of 4022 adults found that participants with children at home were more likely to increase the frequency of consuming alcohol along with other unhealthy foods (eg, snacks and sugared beverages) [42].

On the contrary, some studies indicated patterns of decreased parental drinking during the pandemic. In the United States, Weerakoon et al [41] found that there was no significant increase or decrease in parental drinking compared with participants with no children living at home (n=1928, 42% parents); moreover, having children in the household was associated with a decreased risk of binge drinking. Similarly, in Canada, Zajacova et al [31] found that in a sample of 4319 adults (of whom, 30% (n=1296) had children aged <18 years at home), having children at home was associated with a lower rate of alcohol consumption. A 13-wave longitudinal study of Australian parents found that the frequency of alcohol use decreased over time, although there was no pre–COVID-19 consumption comparison [45]. In a large study of 35 Latin American countries (N=12,328), the majority of participants endorsed decreased drinking during the COVID-19 pandemic when compared with prepandemic levels of drinking [56].

Studies carried out in Europe indicate a mixture of findings. In a study of 63,194 adults in the Netherlands, Mangot-Sala et al [50] found that when comparing adults living with children at home to adults living without children at home and adults living alone, adults living with children drank less than the other 2 groups, suggesting that having children at home was protective in terms of drinking behaviors. Households with children reported a transient increase in drinking to prepandemic levels only during the summer months when restrictions were relaxed and families were more likely to gather, socialize, and engage in drinking with others [50]. In a European study of 6720 parents from (in the order of the largest number of participants per country) Germany, Sweden, Spain, Italy, Belgium, the United Kingdom, and the Netherlands, the proportion of parents who endorsed increased drinking during the COVID-19 pandemic (5%) were largely concentrated in the United Kingdom, with 19% (N=509) of UK parents reporting increases in drinking behaviors [53]. This contrasts with the findings of another UK-based longitudinal study, which found that having children at home was associated with lower odds of increased consumption [51]. A multiround cross-sectional study of adults in Germany found that participants who had children had higher odds of increased alcohol use frequency during the first lockdown (not significant) as well as during the easement of restrictions (significant) but lower odds during the second lockdown (not significant) [49].

In Australia, using a qualitative study of parents, Cook et al [13] found that while many parents in the sample indicated that they increased their frequency of alcohol consumption, some reported that they used the COVID-19 pandemic as an opportunity to lower their frequency of drinking through the absence of social opportunities for drinking.

Mixed Patterns of Drinking Among Mothers and Fathers

Several studies indicated that fathers were more likely than mothers to increase drinking during the COVID-19 pandemic in North America [26,29,37], Australia [45,47], and the United Kingdom [52]. This is in contrast to a global study by Kyaw Hla et al [21], where they found middle-aged, educated women with children at home to be a high-risk group for increased alcohol use during lockdowns. Hill MacEachern et al [27] also identified that, among parent participants, women had slightly higher odds of reporting increases in alcohol consumption when compared with men. Homeschooling was a significant predictor for increased drinking during the pandemic in North America [24] and Australia [43]. Moreover, in a Canadian sample of parents, having to engage in homeschooling for children had an effect on maternal drinking. Desroches et al [25] found that mothers spent more time homeschooling than fathers and that both parents drank more when mothers spent more time homeschooling. Moreover, mothers drank less when fathers spent more time homeschooling [25]. Across their European sample (N=6720), Thorell et al [53] found that across subsamples from Sweden, Spain, Belgium, the Netherlands, Germany, Italy, and the United Kingdom, only 5% of homeschooling parents reported increased alcohol use. Freisthler and Price Wolf [34] investigated mothers’ drinking patterns in a longitudinal study of US mothers via 3 waves of data collection (springtime of 2020, 2021, and 2022). Mothers reported significantly more days of alcohol consumption in the first wave when compared with the second and third waves; however, the average number of drinks consumed during a drinking day was greater in waves 2 and 3 [34]. In the qualitative study by Cook et al [13], one of the participants described how her own drinking habits changed while homeschooling during the pandemic:

But then by mid-April, I was completely out of work and we were still homeschooling, then drinking started about lunchtime, like come on, it’s 12 o’clock, it’s 5 o’clock somewhere, right.
[Woman, Queensland]

While Thomson et al [29] did not specifically examine homeschooling, they found that looking after children while working from home was associated with higher odds of increased alcohol consumption.

Heterogenous Linkages Between Parental Patterns of Alcohol Use and Mental Health

Several studies looked at alcohol use as a coping mechanism for stress. In Australia, Johnson et al [46] found that parenting stress modestly correlated with the Alcohol Use Disorders Identification Test scores. In Canada, using path analysis, Wardell et al [30] found that having children at home was associated with greater alcohol consumption as a method of coping with pandemic stressors.

The findings regarding the relationships between alcohol consumption and mental health were mixed. Lamar et al [37] found a significant correlation between mental health symptoms (stress, depression, and anxiety) and increases in alcohol consumption in the United States. Qualitatively, parents in Australia described that partaking in alcohol consumption at the end of the day delineated a shift from time spent on the care of children to time for self and served a means of self-medicating stress and anxiety [13]. Garcia-Cerde et al [56] found anxiety to be a weak predictor of drinking with children present in Latin American countries. Thomson et al [29] and Joyce et al [28], in their Canadian studies, did not find a significant link between increased drinking and mental health symptoms, although Joyce et al [28] reported that mothers with a history of a previously existing anxiety disorder or elevated anxiety symptoms were more likely to increase their substance use. Notably, an alcohol use tracking app (Habit Tracker) that collected data from 83 countries (the majority from the United Kingdom and the United States) found that although participants with children (209/1134, 18.4% of the sample) indicated significant increases in drinking severity based on their Alcohol Use Disorders Identification Test–Consumption scores, their levels of depression and anxiety were lower relative to adults with no children, suggesting a protective effect of having children at home [22].

Discussion

Principal Findings

The findings of this scoping review provide a broad examination of the patterns of parental alcohol consumption during the COVID-19 pandemic. The global patterns of parental alcohol use were heterogeneous and were influenced by the stage of COVID-19 data collection and sociocultural contexts. Most of the studies clustered around the first year and a half of the pandemic with regard to data collection. While lockdown measures were associated with increased frequency and quantity of alcohol consumption for some Western, industrialized countries, notably the United States, Canada, Australia, and the United Kingdom, a number of studies found patterns of decreased consumption. In Latin American and European Union countries especially, lockdown restrictions eliminated opportunities for socializing and drinking outside the home. Although these findings were mixed, there have been concerning reports of increased alcohol-related deaths; a recent Statistics Canada [58] report indicated an 18% increase in alcohol-related deaths during the COVID-19 pandemic when compared to previous years and that this was the largest change in alcohol-related deaths over the past 20 years. Similarly, in the United States, there were relative increases in deaths when comparing 2019 and 2020 rates of alcohol-related mortality [59], with childbearing-aged adults (ie, those aged 25 to 44 years) experiencing the largest increases. Angus et al [60] also found that the rate of alcohol-related deaths (characterized as “deaths of despair”) increased in the United Kingdom during the COVID-19 pandemic. However, these reports did not distinguish adults who were parenting and those who were not.

Although we had expected to find an association between income support and alcohol use, many of the included studies did not focus on income as a predictor of alcohol use, with the exceptions of the study by Westrupp et al [47], which found a modest association between financial deprivation and lower alcohol use in Australia, and the study by Garcia-Cerde et al [56], which found that individuals with a higher income were more likely to drink with children present. McAloney-Kocaman et al [51], Greenwood et al [45], and Nordeck et al [38] did not separate parents from nonparents when examining the relationship between income and alcohol use and similarly found that lower income predicted decreased use. This contrasts with findings from the United Kingdom, which identified that the most socioeconomically disadvantaged households increased their alcohol purchases more than the least disadvantaged households [61].

In our study, we found some differences in the gender-related patterns of parental drinking, with some findings suggesting that fathers were more likely to increase overall alcohol consumption. Nonetheless, having to homeschool their children contributed to mothers’ increases in drinking. Homeschooling and the provision of childcare during day care closures were responsibilities that fell disproportionately on mothers [62], with women also bearing greater employment-related consequences, such as the reduction of work hours and job loss related to childcare responsibilities [63]. The marketing of alcohol to mothers through social media was especially rampant (eg, through the use of hashtags such as #sendwine and slogans such as “from wifi to wine time #distance learning”), which calls into question the ethics of unmitigated marketing by the alcohol industry [10,14]. In the United States, gender-related differences in drinking behaviors have changed over time, with increases in rates of alcohol consumption in adult women [64]. Some studies indicate both mothers and fathers tend to decrease drinking during the transition to parenthood, with little difference between genders [65]. Meanwhile, other studies indicate that parenting children aged <1 year was associated with lower maternal drinking rates, whereas men’s drinking habits changed little in response to parenthood [66]. Looking at overall drinking habits, fathers have been shown to be less likely to abstain from alcohol than mothers and consume greater volumes of alcohol [67]. Age has also been shown to be a factor, with young fathers more likely to partake in risky drinking behaviors than young mothers [67]. A systematic review of population-level alcohol policy interventions indicated evidence of gender-related differences in the impact of and exposure to alcohol marketing and failure to provide gender-specific recommendations [68].

Beyond the risk to parents’ own health are the possible effects of parental alcohol consumption on children. Children are inevitably exposed to parental alcohol use in the home environment, and parents may even provide alcohol for older or adolescent children as a way to “safely” introduce children to alcohol in a parent-controlled home setting [69,70]. In the United States, Maggs et al [71] found that in 1 in 6 families, parents permitted their adolescents to drink in the home with the family during the COVID-19 pandemic, changing from prepandemic family practices of not permitting adolescent drinking at home. Evidence indicates that parents supplying even sips of alcohol to children carries increased risks of adverse alcohol outcomes, such as adolescent binge drinking, while parental supply of whole drinks was associated with higher odds of binge drinking, alcohol-related harms, and symptoms of dependence for teens [69]. Taken together, there is reason to continue to investigate parental patterns of alcohol consumption, given the range of negative short- and long-term health outcomes for children.

Strengths and Limitations

Strengths of this scoping review include the systematic search process followed. The findings of this scoping review are limited by the heterogeneous ways in which alcohol consumption was measured and the fact that not all studies had data on patterns of consumption before the COVID-19 pandemic for comparison purposes. This review includes a large number of studies from early in the pandemic and hence does not provide the complete picture of the patterns of parental alcohol consumption from the beginning of the COVID-19 pandemic in 2020 to the removal of pandemic-related restrictions during 2022 and 2023. Moreover, although the included studies differentiated patterns of alcohol consumption among parenting adults and nonparenting adults, a limited number of studies differentiated drinking habits between genders in parenting adults, which limited the provision of a more granular examination of the association between gender and alcohol consumption habits in parents.

Clinical Implications and Future Directions

Parental drinking can adversely affect children indirectly through parent preoccupation and the diversion of parental attention and supervision and directly through physical and verbal violence in the home setting and influence children’s later drinking habits [67,72]. In the 2023 Canada’s Guidance on Alcohol and Health [73] report, the Canadian Centre for Substance Use and Addiction indicated that consuming >2 standard drinks per week heightens risks for breast and colon cancers, heart disease, and stroke, with the consumption of >6 drinks per week representing high risk of harms. In line with these strong recommendations for reducing alcohol intake to decrease health and social risks, clinicians who work with families (eg, primary care providers, nurses, and social workers) can inquire about clients’ frequency and amount of alcohol consumption and counsel strategies for moderating or reducing consumption. The findings of this review suggest that parents caring for children are a population that requires more empirical investigation in relation to the amounts and frequency of alcohol consumption and problematic alcohol use. Gender–based data analysis of parental drinking behaviors is also important for informing interventions and policies to promote safe alcohol use among parents. Because parents effectively serve as role models for children, their drinking habits can influence children’s later drinking behaviors. It is important to better understand how to assist parents in moderating alcohol intake, given the risks of unmitigated alcohol consumption.

Conclusions

Our scoping review indicated that the COVID-19 pandemic influenced patterns of parental alcohol consumption in different ways. Sociocultural influences contributed to determining whether having children at home was a protective or risk factor for alcohol consumption. In countries where drinking alcohol is more likely to occur in social settings, such as at bars or restaurants (eg, Latin American and some European countries), parental consumption tended to decrease during the lockdown restrictions, while in countries where drinking in the home environment is the norm (eg, the United States, Canada, the United Kingdom, and Australia), parental consumption tended to increase. Given the known harms of alcohol, clinicians can initiate conversations about parental drinking habits and counsel moderation for parents who report amounts of drinking higher than national guidelines.