ABSTRACT

Objective:

To describe the prevalence of alcohol consumption before and during the COVID-19 pandemic and to analyze the factors associated with this behavior during the period of social distancing among Brazilian adolescents.

Methods:

Cross-sectional study using data from the ConVid Adolescents survey, carried out via the Internet between June and September 2020. The prevalence of alcohol consumption before and during the pandemic, as well as association with sociodemographic variables, mental health, and lifestyle were estimated. A logistic regression model was used to assess associated factors.

Results:

9,470 adolescents were evaluated. Alcohol consumption decreased from 17.70% (95%CI 16.64–18.85) before the pandemic to 12.80% (95%CI 11.85–13.76) during the pandemic. Alcohol consumption was associated with the age group of 16 and 17 years (OR=2.9; 95%CI 1.08–1.53), place of residence in the South (OR=1.82; 95%CI 1.46–2.27) and Southeast regions (OR=1.33; 95%CI 1.05–1.69), having three or more close friends (OR=1.78; 95%CI 1.25–2.53), reporting worsening sleep problems during the pandemic (OR=1.59; 95%CI 1.20–2.11), feeling sad sometimes (OR=1,83; 95%CI 1,40–2,38) and always (OR=2.27; 95%CI 1.70–3.05), feeling always irritated (OR=1,60; 95%CI 1,14–2,25), being a smoker (OR=13,74; 95%CI 8.63–21.87) and a passive smoker (OR=1.76; 95%CI 1.42–2.19). Strict adherence to social distancing was associated with lower alcohol consumption (OR=0.40; 95%CI 0.32–0.49).

Conclusions:

The COVID-19 pandemic led to a decrease in consumption of alcoholic beverages by Brazilian adolescents, which was influenced by sociodemographic and mental health factors, adherence to social restriction measures and lifestyle in this period. Managers, educators, family and the society must be involved in the articulation of Public Policies to prevent alcohol consumption.

Keywords:
Underage drinking; Adolescent; COVID-19; Health surveys; Brazil

INTRODUCTION

The World Health Organization (WHO) declared the COVID-19 situation as a pandemic in March 2020¹1 Cucinotta D, Vanelli M. WHO declares COVID19 a pandemic. Acta Biomed 2020; 91(1): 157-60. https://doi.org/10.23750/abm.v91i1.9397
https://doi.org/10.23750/abm.v91i1.9397... . To minimize the spread of the coronavirus, which causes the disease, social distancing measures were adopted in several Brazilian states and cities, with suspension of classes, closure of non-essential businesses, restrictions on travel, among others, resulting in lower social interaction²2 Szwarcwald CL, Souza Júnior PRB, Malta DC, Barros MBA, Magalhães MAFM, Xavier DR, et al. Adherence to physical contact restriction measures and the spread of COVID-19 in Brazil. Epidemiol Serv Saude 2020; 29(5): e2020432. https://doi.org/10.1590/S1679-49742020000500018
https://doi.org/10.1590/S1679-4974202000... ,³3 Malta DC, Gomes CS, Szwarcwald CL, Barros MBA, Silva AG, Prates EJS, et al. Distanciamento social, sentimento de tristeza e estilos de vida da população brasileira durante a pandemia de Covid-19. Saúde Debate 2020; 44(4): 177-90. https://doi.org/10.1590/0103-11042020E411
https://doi.org/10.1590/0103-11042020E41... . Studies show numerous negative repercussions of measures to restrict social interaction for the health of adolescents⁴4 Malta DC, Gomes CS, Barros MBA, Lima MG, Silva AG, Cardoso LSM, et al. The COVID-19 pandemic and changes in the lifestyles of Brazilian adolescents. Rev Bras Epidemiol 2021; 24: e210012. https://doi.org/10.1590/1980-549720210012
https://doi.org/10.1590/1980-54972021001... –⁶6 Szwarcwald CL, Malta DC, Barros MBA, Souza Júnior PRB, Romero D, Almeida WS, et al. Associations of sociodemographic factors and health behaviors with the emotional well-being of adolescents during the covid-19 pandemic in Brazil. Int J Environ Res Public Health 2021; 18(11): 6160. https://doi.org/10.3390/ijerph18116160
https://doi.org/10.3390/ijerph18116160... , such as increased symptoms of depression and feelings of anxiety, in addition to worsening of lifestyles and dissatisfaction with life. Mental suffering and feelings such as anxiety, loneliness and sadness can lead to risky consumption of alcoholic beverages and tobacco⁷7 Barreto SM, Passos VM, Giatti L. Healthy behavior among Brazilian young adults. Rev Saude Publica 2009; 43 Suppl 2: 9-17. https://doi.org/10.1590/s0034-89102009000900003
https://doi.org/10.1590/s0034-8910200900... –⁹9 Carlyle KE, Steinman KJ. Demographic differences in the prevalence, co-occurrence, and correlates of adolescent bullying at school. J School Health 2007; 77(9): 623-9. https://doi.org/10.1111/j.1746-1561.2007.00242.x
https://doi.org/10.1111/j.1746-1561.2007... and, in turn, trigger substance abuse and dependence¹⁰10 De Micheli D, Formigoni MLOS. Drug use by Brazilian students: associations with family, psychosocial, health, demographic and behavioral characteristics. Addiction 2004; 99(5): 570-8. https://doi.org/10.1111/j.1360-0443.2003.00671.x
https://doi.org/10.1111/j.1360-0443.2003... ,¹¹11 Committee on Substance Abuse, Kokotailo PK. Alcohol use by youth and adolescents: a pediatric concern. Pediatrics 2010; 125(5): 1078-87. https://doi.org/10.1542/peds.2010-0438
https://doi.org/10.1542/peds.2010-0438... . During the social isolation period, these substances may have been used in an attempt to alleviate unpleasant emotions¹²12 Rogés J, Bosque-Prous M, Colom J, Folch C, Barón-Garcia T, González-Casals H, et al. Consumption of alcohol, cannabis, and tobacco in a cohort of adolescents before and during COVID-19 confinement. Int J Environ Res Public Health 2021; 18(15): 7849. https://doi.org/10.3390/ijerph18157849
https://doi.org/10.3390/ijerph18157849... .

Adolescence is a period of changes and transition to adulthood, and it is common to start using psychoactive substances such as alcohol, tobacco and illicit drugs¹³13 Eaton DK, Kann L, Kinchen S, Shanklin S, Flint KH, Hawkins J, et al. Youth risk behavior surveillance – United States, 2011. MMWR Surveill Summ 2012; 61(4): 1-162. PMID: 22673000–¹⁵15 Malta DC, Porto DL, Melo FCM, Monteiro RA, Sardinha LMV, Lessa BH. Family and the protection from use of tobacco, alcohol, and drugs in adolescents, National School Health Survey. Rev Bras Epidemiol 2011; 14 Suppl 1: 166-77. https://doi.org/10.1590/s1415-790x2011000500017
https://doi.org/10.1590/s1415-790x201100... . Drug consumption tends to increase gradually with age, which may result in dependence¹⁶16 Faeh D, Viswanathan B, Chiolero A, Warren W, Bovet P. Clustering of smoking, alcohol drinking and cannabis use in adolescents in a rapidly developing country. BMC Public Health 2006; 6: 169. https://doi.org/10.1186/1471-2458-6-169
https://doi.org/10.1186/1471-2458-6-169... and exposure to immediate risks such as accidents, violence, unwanted pregnancies and sexually transmitted infections (STIs)¹⁴14 Malta DC, Mascarenhas MDM, Porto DL, Barreto SM, Morais Neto OL. Exposure to alcohol among adolescent students and associated factors. Rev Saude Publica 2014; 48(1): 52-62. https://doi.org/10.1590/s0034-8910.2014048004563
https://doi.org/10.1590/s0034-8910.20140... ,¹⁷17 World Health Organization. Global status report on noncommunicable diseases 2010. Genebra: WHO; 2011..

Exposure to substances in adolescence is more common in contexts of socialization such as parties, get-togethers with friends, and usually happens without the awareness and supervision of their guardians¹²12 Rogés J, Bosque-Prous M, Colom J, Folch C, Barón-Garcia T, González-Casals H, et al. Consumption of alcohol, cannabis, and tobacco in a cohort of adolescents before and during COVID-19 confinement. Int J Environ Res Public Health 2021; 18(15): 7849. https://doi.org/10.3390/ijerph18157849
https://doi.org/10.3390/ijerph18157849... ,¹⁶16 Faeh D, Viswanathan B, Chiolero A, Warren W, Bovet P. Clustering of smoking, alcohol drinking and cannabis use in adolescents in a rapidly developing country. BMC Public Health 2006; 6: 169. https://doi.org/10.1186/1471-2458-6-169
https://doi.org/10.1186/1471-2458-6-169... ,¹⁸18 Malta DC, Machado ÍE, Felisbino-Mendes MS, Prado RR, Pinto AMS, Oliveira-Campos M, et al. Use of psychoactive substances among Brazilian adolescents and associated factors: National School-based Health Survey, 2015. Rev Bras Epidemiol 2018; 21(suppl 1): e180004. https://doi.org/10.1590/1980-549720180004.supl.1
https://doi.org/10.1590/1980-54972018000... . Some studies pointed out that, during the pandemic, adolescents spent more time with their parents, away from school and from friends and colleagues, which would have reduced access to these substances and, hence, their consumption¹¹11 Committee on Substance Abuse, Kokotailo PK. Alcohol use by youth and adolescents: a pediatric concern. Pediatrics 2010; 125(5): 1078-87. https://doi.org/10.1542/peds.2010-0438
https://doi.org/10.1542/peds.2010-0438... ,¹⁹19 Bade R, Simpson BS, Ghetia M, Nguyen L, White JM, Gerber C. Changes in alcohol consumption associated with social distancing and self-isolation policies triggered by COVID-19 in South Australia: a wastewater analysis study. Addiction 2021; 116(6): 1600-5. https://doi.org/10.1111/add.15256
https://doi.org/10.1111/add.15256... –²¹21 Dumas TM, Ellis W, Litt DM. What does adolescent substance use look like during the COVID-19 pandemic? Examining changes in frequency, social contexts, and pandemic-related predictors. J Adolesc Health 2020; 67(3): 354-61. https://doi.org/10.1016/j.jadohealth.2020.06.018
https://doi.org/10.1016/j.jadohealth.202... . However, some other studies have suggested that, in the same period, adolescents were more exposed to risk situations and managed to maintain high alcohol consumption¹²12 Rogés J, Bosque-Prous M, Colom J, Folch C, Barón-Garcia T, González-Casals H, et al. Consumption of alcohol, cannabis, and tobacco in a cohort of adolescents before and during COVID-19 confinement. Int J Environ Res Public Health 2021; 18(15): 7849. https://doi.org/10.3390/ijerph18157849
https://doi.org/10.3390/ijerph18157849... ,²¹21 Dumas TM, Ellis W, Litt DM. What does adolescent substance use look like during the COVID-19 pandemic? Examining changes in frequency, social contexts, and pandemic-related predictors. J Adolesc Health 2020; 67(3): 354-61. https://doi.org/10.1016/j.jadohealth.2020.06.018
https://doi.org/10.1016/j.jadohealth.202... ,²²22 Maggs JL. Adolescent life in the early days of the pandemic: less and more substance use. J Adolesc Health 2020; 67(3): 307-8. https://doi.org/10.1016/j.jadohealth.2020.06.021
https://doi.org/10.1016/j.jadohealth.202... .

In Brazil, according to a study analyzing data from the ConVid Adolescents — Research of Behaviors survey, the consumption of alcoholic beverages among Brazilian adolescents has decreased⁴4 Malta DC, Gomes CS, Barros MBA, Lima MG, Silva AG, Cardoso LSM, et al. The COVID-19 pandemic and changes in the lifestyles of Brazilian adolescents. Rev Bras Epidemiol 2021; 24: e210012. https://doi.org/10.1590/1980-549720210012
https://doi.org/10.1590/1980-54972021001... . However, studies carried out in Brazil on this topic did not assess the factors associated with this behavior. Therefore, it is important to identify the effect of social distancing on the consumption of risky substances by Brazilian adolescents and the most affected groups in order to orient public health policies and contribute to the formulation of guidelines for future periods of distancing.

The objectives of this study were to describe the prevalence of alcohol consumption by Brazilian adolescents before and during the COVID-19 pandemic and to analyze the factors associated with this behavior in the period of social distancing.

METHODS

Cross-sectional study aiming to assess the database of the survey ConVid Adolescents — Behavior Research on virtual health, with eyes to the changes in the lives of Brazilian adolescents due to the COVID-19 pandemic.

Data were collected via the Internet, between June 27 and September 17 2020, through a self-completion questionnaire applied on a cell phone or computer. The questionnaire was built using the Research Electronic Data Capture (RedCap) application and addressed sociodemographic characteristics and changes in lifestyle, routine activities, mood and familial relationships in the period of social distancing (available at: https://convid.fiocruz.br/index.php?pag=questionario_adolescente). The information was stored on the server of the Oswaldo Cruz Foundation Institute for Scientific and Technological Communication and Information in Health (ICICT/FIOCRUZ).

Adolescents aged 12 to 17 years living in the Brazilian territory were included in the study. This age group was chosen per the definition of adolescence in the Child and Adolescent Statute²³23 Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Lei no 8.069, de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências [Internet]. Brasília: Diário Oficial da União; 1990 [cited on May 10, 2022]. Available at: https://www.planalto.gov.br/ccivil_03/leis/l8069.htm#:∼:text=LEI%20N%C2%BA%208.069%2C%20DE%2013%20DE%20JULHO%20DE%201990.&text=Disp%C3%B5e%20sobre%20o%20Estatuto%20da,Adolescente%20e%20d%C3%A1%20outras%20provid%C3%AAncias.&text=Art.%201%C2%BA%20Esta%20Lei%20disp%C3%B5e,%C3%A0%20crian%C3%A7a%20e%20ao%20adolescente
https://www.planalto.gov.br/ccivil_03/le... . Participants were invited through a chain sampling procedure called a virtual “snowball”²⁴24 Costa BRL. Bola de neve virtual: o uso das redes sociais virtuais no processo de coleta de dados de uma pesquisa científica. Rev Interdisc Gestão Social 2018; 7(1): 15-37. http://dx.doi.org/10.9771/23172428rigs.v7i1.24649
http://dx.doi.org/10.9771/23172428rigs.v... , which began with sending the questionnaire link to researchers who had experience in studies with adolescents. These researchers, in turn, sent the link to adults in their social networks who were responsible for adolescents. These adults were asked to invite at least three parents or guardians of other adolescents, so the invitations were sent to adults, who were asked: “Do you have children or are you responsible for adolescents in the age range of 12 to 17 years old?”. Only those who answered positively received the free and informed consent form with explanations about the study, a link for contact and clarifications about the research, as well as a request for consent to participate to the adolescents under their responsibility.

Upon signing of the informed consent form by an adult responsible for each adolescent, they received the free and informed assent form; only then did the participants fill out the questionnaire. Additionally, the research coordination sent letters to the directorate of state departments and schools, inviting them to send the link of the questionnaire to adolescents and their parents/guardians. The final sample consisted of 9,470 adolescents.

Since chain sampling is not probabilistic, in order to obtain a representative sample of the population, according to geographic location and sociodemographic characteristics, post-stratification procedures were used to apply weightings²⁵25 Szwarcwald CL, Damacena GN. Amostras complexas em inquéritos populacionais: planejamento e implicações na análise estatística dos dados. Rev Bras Epidemiol 2008; 11(suppl 1): 38-45. https://doi.org/10.1590/S1415-790X2008000500004
https://doi.org/10.1590/S1415-790X200800... . The sample was calibrated using data from the National School Health Survey (PeNSE, 2015) carried out by the Brazilian Institute of Geography and Statistics (IBGE) in partnership with the Ministry of Health, aiming at the same distribution by region of residence, biological sex, age group (12-15 years and 16-17 years), and school network (public or private).

Consumption of alcoholic beverages before and during the pandemic was analyzed, considering the following questions:

1. “Before the pandemic, were you used to consuming alcoholic beverages at parties, get-togethers with friends, etc.?” (Yes/No);

2. “During the pandemic:

   1. I did not drink alcohol;

   2. I am drinking less alcohol than I used to;

   3. I continued drinking alcohol with the same frequency;

   4. I am drinking more alcohol than I used to.”

Adolescents who answered “yes” to question A (before the pandemic) and chose options 2, 3 or 4 to answer about the pandemic period were considered consumers of alcoholic beverages.

In order to analyze the factors associated with the consumption of alcoholic beverages during the pandemic, the explanatory variables were:

1. Sociodemographic:

   1. biological sex: male or female;

   2. age group: 12 to 15 years and 16 and 17 years. The categorization of age groups was based on the fact that, from 16 years of age on, adolescents have more civil liability, answering personally for their actions, which can impact the decision to consume alcoholic beverages—prohibited by law until the age of 18²⁶26 Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Lei no 10.406, de 10 de janeiro de 2002. Institui o Código Civil [Internet]. Brasília: Diário Oficial da União; 2002 [cited on May 10, 2022]. Available at: https://www.planalto.gov.br/ccivil_03/LEIS/2002/L10406.htm#art3i.
      https://www.planalto.gov.br/ccivil_03/LE... .

   3. skin color: white, black, brown, other;

   4. school network: private or public;

   5. maternal education: primary education or less, high-school, higher education;

   6. region: North, Northeast, South, Southeast and Midwest.

2. Adherence to social restriction measures:

   1. Not very strict: “I didn't do anything, I had a normal life”, “I tried to be cautious, stay away from people, reduce contact a little, not visit the elderly, but I kept going out”, “I just stopped going to school, but I continued doing other activities normally”.

   2. Very strict: “I stayed at home most days, going out to visit close relatives, shopping at the supermarket and pharmacy” and “I stayed strictly at home, going out only for health care needs”.

3. Mental health:

   1. number of close friends: none, one friend, two friends, three or more friends;

   2. quality of sleep during the pandemic: not affected, began to have sleep problems, sleep problems were maintained, sleep problems worsened, sleep problems reduced.

   3. feeling sad or depressed: never/rarely, sometimes, most of the time/always.

   4. feeling irritable: never/rarely, sometimes, most of the time/always.

   5. feeling isolated: never/rarely, sometimes, most of the time/always.

4. Lifestyle:

   1. smoking during the pandemic: yes, no;

   2. passive smoker: yes, no;

   3. sedentary behavior: maintained, increased, reduced. Sedentary behavior was considered to be sitting for three or more hours a day, watching television, playing video games, using a computer, cell phone, tablet or doing other activities while sitting down.

   4. Practice of physical activity during the pandemic: maintained, increased, reduced. At least one hour on five or more days a week of activities was considered as physical exercise²⁷27 World Health Organization. Global action plan on physical activity 2018–2030: more active people for a healthier world. Geneva: WHO; 2018..

The prevalence of alcohol consumption before and during the pandemic was estimated for the total sample and according to exposure variables, with respective 95% confidence intervals (95%CI). To verify possible factors associated with the consumption of alcoholic beverages during the pandemic, univariate and multivariate logistic regression models were used. All variables with p<0.2 in the univariate analysis were selected for the multivariate model. The significance level adopted for the multivariate analysis was 5%.

All analyses were performed using the Software for Statistics and Data Science (Stata) version 14.0 and considered post-stratification weights.

The research was approved by the National Committee for Ethics in Research (Opinion No. 4,100,515). The adolescents’ parents or guardians signed an informed consent form, followed by the assent form by the adolescents themselves, and participants were not identified.

RESULTS

A total of 9,470 adolescents were evaluated; 50.2% (95%CI 48.6–51.9) were females, 67.7% (95%CI 66.3–69.1) were aged between 12 and 15 years old. Most of them reported being brown (46.6%; 95%CI 44.9–48.3), followed by white (40.1%; 95%CI 38.5–41.7), and studying in public schools (85.9%; 95%CI 85.1–86.7). As for maternal education, the distribution was similar, around one third in each group (Table 1).

Consumption of alcoholic beverages was reported by 17.70% of participants (95%CI 16.64–18.85) before the pandemic, and reduced to 12.8% (95%CI 11.85–13.76) during the pandemic. There was a reduction among males (from 15.01 to 11.37%) and females (from 20.4 to 14.15%), in both cases, in the age groups analyzed: from 12 to 15 years (from 11.56 to 8.55%) and 16 and 17 years old (from 30.61 to 21.61%) (Figure 1).

As for the factors associated with the use of alcoholic beverages during social isolation, the univariate model showed a greater chance of this behavior among female adolescents (OR=1.29; 95%CI 1.08–1.53); aged 16 and 17 years (OR=2.95; 95%CI 2.48–3.51); participants living in the South (OR=1.93; 95%CI 1.59–2.35) and Southeast (OR=1.60; 95%CI 1.30–1.98) regions, compared with those living in the North Region; who had three or more close friends (OR=1.42; 95%CI 1.05–1.93); who reported starting to have sleep problems (OR=1.53; 95%CI 1.22–1.93), maintained sleep problems (OR=1.81; 95%CI 1.38–2.37) and worsened sleep problems (OR=2.78; 95%CI 2.23–3.46) during the pandemic; who reported feeling sad sometimes (OR=2.19; 95%CI 1.71–2.80) and always (OR=3.15; 95%CI 2.51–3.97); feeling irritated sometimes (OR=1.56; 95%CI 1.15–2.12) and always (OR=2.67; 95%CI 2.03–3.51); feeling isolated sometimes (OR=1.89; 95%CI 1.50–2.38) and always (OR=2.30; 95%CI 1.84–2.88); adolescents who actively smoked (OR=18.33; 95%CI 12.40–27.14) or were passive smokers (OR=2.26; 95%CI 1.86–2.74); and those who had sedentary behavior worsened (OR=1.33; 95%CI 1.11–1.59).

On the other hand, brown skin adolescents (OR=0.80; 95%CI 0.66–0.96), who studied in private schools (OR=0.70; 95%CI 0.58–0.85), whose mothers had higher education (high school — OR=0.69; 95%CI 0.56–0.86; higher education — OR=0.72; 95%CI 0.58–0.90) and who adopted social distancing measures rigorously (OR=0.46; 95%CI 0.38–0.55) were less likely to consume alcoholic beverages during the pandemic (Table 2).

In the multivariate model, the following variables were associated with higher consumption of alcoholic beverages: age group of 16 and 17 years (OR=2.90; 95%CI 2.39–3.51); living in the South (OR=1.82; 95%CI 1.46–2.27) and Southeast regions (OR=1.33; 95%CI 1.05–1.69); having three or more close friends (OR=1.78; 95%CI 1.25–2.53); worsened sleep problems during the pandemic (OR=1.59; 95%CI 1.20–2.11); feeling sad sometimes (OR=1.83; 95%CI 1.40–2.38) and always (OR=2.27; 95%CI 1.77–3.12); always feeling irritable (OR=1.60; 95%CI 1.14–2.25); and being an active (OR=13.74; 95%CI 8.63–21.87) or passive smoker (OR=1.76; 95%CI 1.42–2.19). Meanwhile, lower consumption of alcoholic beverages was associated with very strict adherence to social distancing measures (OR=0.40; 95%CI 0.32–0.49) (Table 2).

DISCUSSION

This study detected a decrease in alcohol consumption during the pandemic, which was reported by about a fifth of the participating adolescents. Regarding those who consumed alcoholic beverages in the period, the highest consumption was among older adolescents (16 and 17 years old) who lived in the South and Southeast regions, with three or more close friends, who reported worse sleep and feelings of sadness and irritability, and reported being active and passive smokers. Consumption was lower by adolescents who took very strict social distancing measures during the pandemic.

The reduction in prevalence of alcohol consumption during the pandemic, observed in the present study is in line with other studies¹²12 Rogés J, Bosque-Prous M, Colom J, Folch C, Barón-Garcia T, González-Casals H, et al. Consumption of alcohol, cannabis, and tobacco in a cohort of adolescents before and during COVID-19 confinement. Int J Environ Res Public Health 2021; 18(15): 7849. https://doi.org/10.3390/ijerph18157849
https://doi.org/10.3390/ijerph18157849... ,²⁸28 Clare PJ, Aiken A, Yuen WS, Upton E, Kypri K, Degenhardt L, et al. Alcohol use among young Australian adults in May-June 2020 during the COVID-19 pandemic: a prospective cohort study. Addiction 2021; 116(12): 3398-407. https://doi.org/10.1111/add.15599
https://doi.org/10.1111/add.15599... . It may be related to numerous factors, mainly less opportunities to participate in parties, celebrations and get-togethers with friends due to the guidelines for social distancing¹²12 Rogés J, Bosque-Prous M, Colom J, Folch C, Barón-Garcia T, González-Casals H, et al. Consumption of alcohol, cannabis, and tobacco in a cohort of adolescents before and during COVID-19 confinement. Int J Environ Res Public Health 2021; 18(15): 7849. https://doi.org/10.3390/ijerph18157849
https://doi.org/10.3390/ijerph18157849... . PeNSE data showed that the main opportunities to obtain alcoholic beverages are parties (29.2%) and other events in the company of friends (17.7%)²⁹29 Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar (PeNSE) 2019. Rio de Janeiro: IBGE; 2021..

Despite this reduction, the high prevalence of alcohol consumption during the pandemic (12.7%) disturbingly shows the continuity of this behavior among adolescents, even during social distancing. Other studies have already reported that alcohol consumption is high among Brazilian adolescents¹⁹19 Bade R, Simpson BS, Ghetia M, Nguyen L, White JM, Gerber C. Changes in alcohol consumption associated with social distancing and self-isolation policies triggered by COVID-19 in South Australia: a wastewater analysis study. Addiction 2021; 116(6): 1600-5. https://doi.org/10.1111/add.15256
https://doi.org/10.1111/add.15256... ,³⁰30 Horta RL, Horta BL, Pinheiro RT, Morales B, Strey MN. Tabaco, álcool e outras drogas entre adolescentes em Pelotas, Rio Grande do Sul, Brasil: uma perspectiva de gênero. Cad Saude Publica 2007; 23(4): 775-83. https://doi.org/10.1590/s0102-311x2007000400005
https://doi.org/10.1590/s0102-311x200700... . According to PeNSE 2019, 63.3% of students aged 13 to 17 years old at least tried these products and 25%²⁹29 Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar (PeNSE) 2019. Rio de Janeiro: IBGE; 2021. had consumed them in the last 30 days. Similar to Brazil, alcoholic beverages are the drug most consumed by young people in other countries¹³13 Eaton DK, Kann L, Kinchen S, Shanklin S, Flint KH, Hawkins J, et al. Youth risk behavior surveillance – United States, 2011. MMWR Surveill Summ 2012; 61(4): 1-162. PMID: 22673000,¹⁷17 World Health Organization. Global status report on noncommunicable diseases 2010. Genebra: WHO; 2011.,³¹31 World Health Organization. International guide for monitoring alcohol consumption and related harm. Genebra: WHO; 2002.,³²32 Leatherdale ST, Hammond D, Ahmed R. Alcohol, marijuana, and tobacco use patterns among youth in Canada. Cancer Causes Control 2008; 19(4): 361-9. https://doi.org/10.1007/s10552-007-9095-4
https://doi.org/10.1007/s10552-007-9095-... .

The results also pointed to complex relationships between individual and contextual factors, behavioral changes and the use of risky substances by adolescents during the COVID-19 confinement.

Alcohol consumption during the pandemic was almost three times higher in older adolescents. These data are consistent with the findings of PeNSE, according to which adolescents aged 16 and 17 years consume more alcoholic beverages than those aged 13 to 15 years²⁹29 Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar (PeNSE) 2019. Rio de Janeiro: IBGE; 2021.. Despite the closure of leisure establishments and the reduction in social gatherings during the period studied, the older group maintained more freedom to leave the house and, therefore, more opportunities to access psychoactive substances¹⁹19 Bade R, Simpson BS, Ghetia M, Nguyen L, White JM, Gerber C. Changes in alcohol consumption associated with social distancing and self-isolation policies triggered by COVID-19 in South Australia: a wastewater analysis study. Addiction 2021; 116(6): 1600-5. https://doi.org/10.1111/add.15256
https://doi.org/10.1111/add.15256... ,³³33 Currie C, Zanotti C, Morgan A, Currie D, Looze M, Roberts C, et al. Social determinants of health and well-being among young people. Health Behaviour in School-aged Children (HBSC) study: international report from the 2009/2010 survey. Copenhagen: WHO Regional Office for Europe; 2012.. In addition, some parents approved the consumption of alcoholic beverages by older adolescents at home, usually not allowed before³⁴34 Maggs JL, Cassinat JR, Kelly BC, Mustillo SA, Whiteman SD. Parents who first allowed adolescents to drink alcohol in a family context during spring 2020 COVID-19 emergency shutdowns. J Adolesc Health 2021; 68(4): 816-8. https://doi.org/10.1016/j.jadohealth.2021.01.010
https://doi.org/10.1016/j.jadohealth.202... .

Adolescents from the South and Southeast regions had a higher consumption of alcoholic beverages during the pandemic than those living in the North region of the country. This result accompanies the pre-pandemic national prevalence, since adolescents from these regions had a higher rate of trying and consuming alcoholic beverages, as well as more episodes of drunkenness²⁹29 Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar (PeNSE) 2019. Rio de Janeiro: IBGE; 2021..

Adolescents with three close friends or more drank about three times more, which makes it an important marker of use. This indicator reflects the influence of peers on this habit. Previous studies have shown the influence of friends on alcohol consumption, as adolescents with more friends tend to be more popular, which gives them more access to parties, where there is a higher consumption of alcoholic beverages¹⁸18 Malta DC, Machado ÍE, Felisbino-Mendes MS, Prado RR, Pinto AMS, Oliveira-Campos M, et al. Use of psychoactive substances among Brazilian adolescents and associated factors: National School-based Health Survey, 2015. Rev Bras Epidemiol 2018; 21(suppl 1): e180004. https://doi.org/10.1590/1980-549720180004.supl.1
https://doi.org/10.1590/1980-54972018000... . On the other hand, strict social distancing, which reduced the presence of this group at parties and contact with friends, resulted in a drop in alcohol consumption, also described by other studies¹²12 Rogés J, Bosque-Prous M, Colom J, Folch C, Barón-Garcia T, González-Casals H, et al. Consumption of alcohol, cannabis, and tobacco in a cohort of adolescents before and during COVID-19 confinement. Int J Environ Res Public Health 2021; 18(15): 7849. https://doi.org/10.3390/ijerph18157849
https://doi.org/10.3390/ijerph18157849... ,¹⁹19 Bade R, Simpson BS, Ghetia M, Nguyen L, White JM, Gerber C. Changes in alcohol consumption associated with social distancing and self-isolation policies triggered by COVID-19 in South Australia: a wastewater analysis study. Addiction 2021; 116(6): 1600-5. https://doi.org/10.1111/add.15256
https://doi.org/10.1111/add.15256... ,³⁵35 Chodkiewicz J, Talarowska M, Miniszewska J, Nawrocka N, Bilinski P. Alcohol consumption reported during the COVID-19 pandemic: the initial stage. Int J Environ Res Public Health 2020; 17(13): 4677. https://doi.org/10.3390/ijerph17134677
https://doi.org/10.3390/ijerph17134677... .

Our study also identified that alcohol consumption was higher among adolescents who reported symptoms of mental health worsening, such as feelings of sadness, irritation and poor sleep quality. The pandemic meant, for most adolescents, distancing from friends and a change in routine, as many remained alone at home, which may have influenced the increase in feelings of sadness and irritability, and worsening of sleep quality⁴4 Malta DC, Gomes CS, Barros MBA, Lima MG, Silva AG, Cardoso LSM, et al. The COVID-19 pandemic and changes in the lifestyles of Brazilian adolescents. Rev Bras Epidemiol 2021; 24: e210012. https://doi.org/10.1590/1980-549720210012
https://doi.org/10.1590/1980-54972021001... ,⁶6 Szwarcwald CL, Malta DC, Barros MBA, Souza Júnior PRB, Romero D, Almeida WS, et al. Associations of sociodemographic factors and health behaviors with the emotional well-being of adolescents during the covid-19 pandemic in Brazil. Int J Environ Res Public Health 2021; 18(11): 6160. https://doi.org/10.3390/ijerph18116160
https://doi.org/10.3390/ijerph18116160... . In this setting, some adolescents may have used risky substances as a way of dealing with bad feelings in the social distancing phase¹²12 Rogés J, Bosque-Prous M, Colom J, Folch C, Barón-Garcia T, González-Casals H, et al. Consumption of alcohol, cannabis, and tobacco in a cohort of adolescents before and during COVID-19 confinement. Int J Environ Res Public Health 2021; 18(15): 7849. https://doi.org/10.3390/ijerph18157849
https://doi.org/10.3390/ijerph18157849... ,²¹21 Dumas TM, Ellis W, Litt DM. What does adolescent substance use look like during the COVID-19 pandemic? Examining changes in frequency, social contexts, and pandemic-related predictors. J Adolesc Health 2020; 67(3): 354-61. https://doi.org/10.1016/j.jadohealth.2020.06.018
https://doi.org/10.1016/j.jadohealth.202... ,³⁶36 Niedzwiedz CL, Green MJ, Benzeval M, Campbell D, Craig P, Demou E, et al. Mental health and health behaviours before and during the initial phase of the COVID-19 lockdown: longitudinal analyses of the UK Household Longitudinal Study. J Epidemiol Community Health 2021; 75(3): 224-31. https://doi.org/10.1136/jech-2020-215060
https://doi.org/10.1136/jech-2020-215060... ,³⁷37 Hawke LD, Barbic SP, Voineskos A, Szatmari P, Cleverley K, Hayes E, et al. Impacts of COVID-19 on youth mental health, substance use, and well-being: a rapid survey of clinical and community samples: répercussions de la COVID-19 sur la santé mentale, l'utilisation de substances et le bien-être des adolescents: un sondage rapide d’échantillons cliniques et communautaires. Can J Psychiatry 2020; 65(10): 701-9. https://doi.org/10.1177/0706743720940562
https://doi.org/10.1177/0706743720940562... . In addition, being home alone may have facilitated access to alcoholic beverages, since many guardians had to be away from home to work, which reduced the control and supervision of the underages¹²12 Rogés J, Bosque-Prous M, Colom J, Folch C, Barón-Garcia T, González-Casals H, et al. Consumption of alcohol, cannabis, and tobacco in a cohort of adolescents before and during COVID-19 confinement. Int J Environ Res Public Health 2021; 18(15): 7849. https://doi.org/10.3390/ijerph18157849
https://doi.org/10.3390/ijerph18157849... .

Another factor that was associated with the consumption of alcoholic beverages was the habit of smoking. Studies indicate that tobacco can trigger other risk behaviors, such as drinking³⁸38 Abreu MNS, Eleotério AE, Oliveira FA, Pedroni LCBR, Lacena EE. Prevalence and factors associated with binge drinking among Brazilian young adults, 18 to 24 years old. Rev Bras Epidemiol 2020; 23: e200092. https://doi.org/10.1590/1980-549720200092
https://doi.org/10.1590/1980-54972020009... ,³⁹39 Levinson D, Rosca P, Vilner D, Brimberg I, Stall Y, Rimon A. Binge drinking among young adults in an urban tertiary care emergency department in Israel. Isr J Health Policy Res 2017; 6(1): 34. https://doi.org/10.1186/s13584-017-0156-1
https://doi.org/10.1186/s13584-017-0156-... , with an increase in the feeling of pleasure due to the combination of nicotine and alcohol⁴⁰40 Thrul J, Gubner NR, Tice CL, Lisha NE, Ling PM. Young adults report increased pleasure from using e-cigarettes and smoking tobacco cigarettes when drinking alcohol. Addict Behav 2019; 93: 135-40. https://doi.org/10.1016/j.addbeh.2019.01.011
https://doi.org/10.1016/j.addbeh.2019.01... . Adolescents who reported being passive smokers at home were also more likely to consume alcoholic beverages. Studies show that passive smokers at home are a more vulnerable population⁴¹41 Malta DC, Gomes CS, Andrade FMD, Prates EJS, Alves FTA, Oliveira PPV, et al. Tobacco use, cessation, secondhand smoke and exposure to media about tobacco in Brazil: results of the National Health Survey 2013 and 2019. Rev Bras Epidemiol 2021; 24(suppl 2): e210006. https://doi.org/10.1590/1980-549720210006.supl.2
https://doi.org/10.1590/1980-54972021000... , which may be a marker of homes in which adults supervise and protect less adolescents or even encourage the consumption of alcoholic beverages at home. As reported by PeNSE, approximately 11% of students who consumed alcoholic beverages were given access to the product by someone in their own family²⁹29 Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar (PeNSE) 2019. Rio de Janeiro: IBGE; 2021., which also shows how the consumption of alcoholic beverages is naturalized in Brazilian culture.

Adolescents who adhered strictly to social distancing measures were less likely to consume alcoholic beverages during the pandemic, which may be related to distancing from friends and parties and, consequently, difficulty in accessing them, and better monitoring by parents or guardians about this consumption¹²12 Rogés J, Bosque-Prous M, Colom J, Folch C, Barón-Garcia T, González-Casals H, et al. Consumption of alcohol, cannabis, and tobacco in a cohort of adolescents before and during COVID-19 confinement. Int J Environ Res Public Health 2021; 18(15): 7849. https://doi.org/10.3390/ijerph18157849
https://doi.org/10.3390/ijerph18157849... ,³⁶36 Niedzwiedz CL, Green MJ, Benzeval M, Campbell D, Craig P, Demou E, et al. Mental health and health behaviours before and during the initial phase of the COVID-19 lockdown: longitudinal analyses of the UK Household Longitudinal Study. J Epidemiol Community Health 2021; 75(3): 224-31. https://doi.org/10.1136/jech-2020-215060
https://doi.org/10.1136/jech-2020-215060... .

This is, to date, the first nationally representative study that analyzed factors associated with alcohol consumption by adolescents during the COVID-19 pandemic. However, some limitations need to be mentioned. The sample selected via the Internet, not random, may not have reached all social segments, but sample calibration based on PeNSE data reduced this limitation. Data were collected at a specific time of the pandemic; nowadays, the scenario may be different. Therefore, further studies on other periods of the pandemic are recommended.

As evidenced by the results of this study, the COVID-19 pandemic affected the social life of young people and reduced the consumption of alcoholic beverages by Brazilian adolescents, a phenomenon associated with sociodemographic factors (age and region of residence), adherence to social distancing measures social, events related to mental health (number of friends, quality of sleep and feelings of sadness and irritability) and lifestyle (active and passive smoking and sedentary behavior).

It all evidence that public policies for health promotion and alcohol consumption prevention must be articulated and involve authorities, educators, family and the society. It is urgent to involve the society in the debate on the consumption of alcoholic beverages by adolescents, establishing conditions to advance in the legislation, with better regulation from the supply to the sale of alcoholic beverages, thinking mainly about the prohibition of marketing of these substances, just as there are rules for the sale of cigarettes.

ACKNOWLEDGMENTS:

We would like to thank the National Council for Scientific and Technological Development (CNPq) for the productivity grant to author Deborah Carvalho Malta.

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