Problem drinkers and high risk-taking behaviors under the stay-at-home policy of the COVID-19 emergency declaration

Coronavirus disease 2019 (COVID-19) is an infectious disease that is easily transmitted from person to person through everyday actions such as speaking, singing, breathing, and coughing[1]. In order to control the COVID-19 pandemic, social distancing and hygiene measures were implemented worldwide[2]. According to a national survey in Japan, the majority of the respondents adhered to the countermeasures, which included: avoiding crowded places (78%), universal masking (82%), and washing hands or sanitizing hands with sanitizers (90%)[3]. Meanwhile, many countries stopped international travel, implemented national emergency declarations, and asked people to stay at home as much as possible[4, 5]. Especially before implementing the COVID-19 vaccinations, the national lockdown, and stay-at-home policy was one of the most important prevention protocols. In this regard, many governments not only implemented penalties to those ignoring this policy[6], but they also shut down full-service restaurants/bars and implemented strong restrictions on their services[7, 8].

As for Japan, the government implemented a stay-at-home policy without penalties[9, 10] and requested various facilities, including restaurants/bars, to either temporarily close their businesses or shorten their business hours. In particular, the Japanese government asked its people to stay at home and focused on closing businesses that had clusters of COVID-19 before the first emergency declaration. For example, from January to April 2020, such clusters occurred at healthcare facilities, restaurants/bars, workplaces, music-related events, karaoke (soundproof rooms for singing songs), gymnasiums, ceremonial functions, and airplanes[11]. Meanwhile, local governments provided financial subsidies for the facilities that closed or shortened their business hours under the COVID-19 emergency declaration[12].

Ignoring the stay-at-home policy of the COVID-19 emergency declaration would be regarded as a high risk-taking behavior that increases one’s risk of infection or the possibility of transmitting the virus[1]. Problem drinking is also well known with numerous risk-taking behaviors such as aggressiveness[13, 14], sexual risk taking[15], accident-related injuries and fatalities[16], and drunk driving[17]. Additionally, higher doses of alcohol can potentially increase risky decision-making, compared to lower doses of alcohol[18]. The proportion of lifetime experience of alcohol dependence diagnosed by ICD-10 in Japan was 1.9% (2013) and 0.8% (2018) for men, and 0.2% (2013) and 0.2% (2018) for women in the National periodical surveys[19, 20]. Moreover, 30.5% of males and 7.2% of females had binge drinking[19]. As an aspect of social tools of drinking in Japan, drinking parties or group drinking at pubs or restaurants was held frequently before COVID-19, and the reasons for drinking for binge drinking in group drinking was such as facilitating interpersonal relationships[21]. Drinking was culturally connected to social and outgoing behavior in Japan, but those social interactions were regarded as socially irresponsible behaviors against the stay-at-home policy of the COVID-19. It is not clear what action problem drinkers have taken in response to these regulations. Therefore, this study is the first to examine the association between alcohol use and high risk-taking behaviors under the imposed policy.

This is the first study to investigate the relationship between problem drinking and high risk-taking behaviors against the stay-at-home policy of the COVID-19 emergency declaration. We found that potential alcohol abuse or alcohol use disorder based on a higher CAGE score was strongly associated with high risk-taking behaviors between April and May 2020.

As stated earlier, the Japanese government had asked its people to stay at home in order to avoid transmitting COVID-19 during that time period. In this regard, the largest reduction in the moving population was recorded during the first week of May 2020[26], which was a national holiday week in Japan. In addition, the government emphasized that dining out or gathering with non-family members was a high-risk-taking behavior for transmitting COVID-19[9]. In this regard, a survey by the Japan Foodservice Association[27, 28] showed that the number of izakaya customers in April and May 2020 was only 12.6% and 14.4%, respectively, while the number of pub or beer hall customers in the same period was 4.1% and 3.4%, respectively. However, although the announcement of the stay-at-home policy generally reduced the moving population, it may not have been enough for problem drinkers. For example, the COVID-19 clusters often occurred in situations outside of the home where dining out and drinking alcohol were involved[29].

According to previous research, there is a dose-dependent correlation between alcohol consumption and viral infections[30, 31]. The World Health Organization (WHO) also advised that drinkers should reduce their drinking volume during the COVID-19 pandemic[1]. Hence, taking care of problem drinkers will not only help prevent their infection, but also curb the possible spread of the virus on a wider scale.

A previous study in Japan showed that problem drinkers had generally higher income[32]. Our study extended this evidence by including the following factors: being men, having a higher income and job position, smoking, sleep deprivation, depression, and other mental diseases. In Japanese culture, drinking is an important communication tool in business, especially among middle-aged men at the management level[33]. In addition, Japanese people living in Japan are more tolerant of heavy drinking, compared to those living in other countries such as the United States[34]. According to a survey of 40 nations, Japan had the highest proportion of moral acceptance for drinking alcohol or regard as not moral issue (91%), followed by Canada (88%) and the lowest in Pakistan (3%)[35]. The demographic difference in the social acceptance may reflect the social norms and cultural contexts for drinking and alcohol use (or misuse)[36].

Considering the relationship between alcohol use and high risk-taking behaviors, appropriate actions for problem drinkers may help reduce their outgoing behaviors during a future COVID-19 emergency declaration. For example, the stay-at-home policy in Japan under the first emergency declaration did not include penalties for those who did not follow the imposed policy, but simply focused on compensating various businesses that closed or shortened their business hours. However, a systematic literature review indicated the effectiveness of regulatory enforcement in occupational health and safety[37], such as in Taiwan, where strengthening sanctions for drunk-driving helped in reducing drunk-driving injuries and deaths[38]. In Germany, a study highlighted the effectiveness of penalties for lockdown violations[39]. Alternatively, stakeholders or decision-makers can introduce rewards (instead of penalties) for changes in health-related behaviors[40]. An experimental study using the Risk Dictator Game showed that a large majority of people are reluctant to put others at risk for their personal benefit (money in the game) and were likely to take socially responsible behaviors such as following physical distancing guidelines, staying home when sick, and buying face masks under COVID-19[41]. However, problem drinkers may be unlikely to take socially responsible behaviors by their will. Therefore, governments need to enforce strict regulations for restaurants that do not follow their business restriction under COVID-19. This may assist in preventing problem drinkers who are unlikely to follow socially responsible behaviors due to a lack of self-control from spreading COVID-19. Yet, further research is necessary to identify the type of compensation (or restrictions) that would affect the risk-taking behaviors of problem drinkers or determine whether appropriate intervention for drinkers may reduce such behaviors under a stay-at-home policy.

Using cross-sectional data from a nationwide Internet survey (conducted from August to September 2020), this study examined the association between alcohol use and high risk-taking behaviors under the imposed stay-at-home policy of the first COVID-19 emergency declaration in Japan. Based on the findings, people with potential alcohol use disorder or alcohol abuse were more likely to have risk-taking behaviors, such as dining out at restaurants/bars, visiting friends, or going out somewhere, which may increase the risk of being infected by COVID-19 and/or transmitting the virus to others. The results also indicate that taking certain actions for problem drinkers may have a positive impact on reducing their risk-taking behaviors during the pandemic.