Alcohol Use Patterns During and After the COVID-19 Pandemic Among Veterans in the United States

Abstract

BACKGROUND:

Veterans may be especially susceptible to increased alcohol consumption following the COVID-19 pandemic. We aim to evaluate trends in alcohol use among US Veterans prior to, during, and following the onset of the COVID-19 pandemic.

METHODS:

All US Veterans utilizing Veterans Affairs health care facilities in the United States from March 1, 2018 to February 28, 2023 with ≥1 AUDIT-C score were categorized into 1) No alcohol use (AUDIT-C = 0), 2) Low-risk alcohol use (AUDIT-C 1-2 for women, 1-3 for men), and 3) High-risk alcohol use (AUDIT-C ≥ 3 for women, ≥ 4 for men). Trends in the proportion of Veterans reporting high-risk alcohol use, stratified by sex, age, race/ethnicity, and urbanicity were evaluated.

RESULTS:

Among a cohort of 2.15 to 2.60 million Veterans, 15.5% reported high-risk alcohol use during March 2018-February 2019, which decreased to 14.6% during the first year of the pandemic, increased to 15.2% in the second year, and then decreased to 14.9% from March 2022-February 2023. Among non-Hispanic whites, African Americans, Asians, and Hispanics, the proportion of women reporting high-risk alcohol use surpassed that of men during the onset of the pandemic and beyond. The greatest proportion of high-risk alcohol use was observed among young Veterans ages 18-39 years (17%-27%), which was consistent across all race/ethnic groups.

CONCLUSIONS:

High-risk alcohol use among US Veterans has increased since the COVID-19 pandemic onset, and in the third year following pandemic onset, 15% of Veterans overall and over 20% of young Veterans ages 18-39 years reported high-risk alcohol use.

INTRODUCTION

Studies have reported on alarming increases in alcohol consumption following onset of the COVID-19 pandemic.^1,2 Grossman et al³ surveyed 832 adults in May 2020, among whom 34.1% reported binge drinking in the preceding 30 days, and 60% reported increased drinking compared with the prepandemic period. Surveillance data from the National Institute on Alcohol Abuse and Alcoholism reported that per capita alcohol consumption experienced the largest 2-year increase of any recorded 2-year period from 2019 to 2021.⁴ This alarming increase in alcohol consumption is particularly concerning given parallel increases in health consequences related to unhealthy alcohol use and alcohol-related mortality.^5-7 Veteran populations have high prevalence of mental health comorbidities and behavioral risk factors associated with high-risk alcohol use, and thus, may be especially at risk for increasing alcohol consumption following the pandemic. However, Davis et al⁸ surveyed 1230 US Veterans from February 2020-February 2021 and reported decreases in overall alcohol use and binge drinking in the pandemic’s first year. Few studies have examined longer-term trends in alcohol use beyond the first year of the pandemic, and to the best of our knowledge, no studies to date have examined nationwide trends in alcohol use among US Veterans 3 years after the onset of the pandemic.

METHODS

We retrospectively evaluated Veterans who had at least one documented Alcohol Use Disorders Identification Test (AUDIT-C) score from March 1, 2018 to February 28, 2023 using national data from the Veterans Affairs Corporate Data Warehouse (VA-CDW). The VA-CDW is a national database that captures data on all Veterans utilizing health care services among Veterans Affairs (VA) facilities across the United States. The VA health system is the largest integrated health system in the United States. The VA-CDW captures important demographic data, comorbidities, and risk behaviors such as alcohol use, incorporating longitudinal laboratory data in addition to clinical encounters and clinical outcomes for data analyses and harmonizes data into a single unified dataset, which can facilitate longitudinal assessment of patient outcomes. AUDIT-C scores are routinely assessed as part of health care visits in the VA health system and have been validated in Veteran populations.^9-12 For this study, AUDIT-C scores were categorized as 1) No alcohol use (AUDIT-C = 0), 2) Low-risk alcohol use (AUDIT-C 1-2 for women and 1-3 for men), and 3) High-risk alcohol use (AUDIT-C ≥ 3 for women and ≥ 4 for men).^10,13,14 Trends in alcohol use based on AUDIT-C were evaluated on an annual basis from March 1 to February 28/29 of each corresponding calendar year. March 1 was chosen as the start date of each period analyzed to correspond with the declaration of COVID-19 as a pandemic by the World Health Organization in March 2020: Pre-COVID-19 (March 1, 2018-February 28, 2019 and March 1, 2019-February 29, 2020), COVID-19 Year 1 (March 1, 2020-February 28, 2021), COVID-19 Year 2 (March 1, 2021-February 28, 2022), and COVID-19 Year 3 (March 1, 2022-February 28, 2023).

For each period, the proportion of Veterans with no alcohol use, low-risk alcohol use, and high-risk alcohol use were stratified by race/ethnicity, sex, age groups, and location of current residence (rural vs urban). Race/ethnicity was self-reported and included non-Hispanic white, black or African American, Asian or Pacific Islander, Hispanic, or American Indian or Alaska Native. When an individual had more than one AUDIT-C score documented within a study period, the highest AUDIT-C score was selected for analysis. Comparisons of alcohol use between groups utilized the z-test using standard equations, and the trends test was used to evaluate overall trends in alcohol use patterns over time. Statistical analyses were performed using SQL and SAS Studio 3.6 on SAS 9.4 (SAS Institute Inc., Cary, NC). Statistical significance was met with a 2-tailed P value < .05. This study was approved by Stanford University Institutional Review Board and VA Palo Alto Scientific Research Committee.

RESULTS

The total number of Veterans with a documented AUDIT-C score ranged from 2.15 million to 2.60 million across the different periods analyzed. The proportion of Veterans reporting high-risk alcohol use decreased from 15.5% (95% confidence interval [CI], 15.5-15.6) (March 2018-February 2019) to 14.6% (95% CI, 14.5-14.6) during COVID-19 Year 1, increased to 15.2% (95% CI, 15.1-15.2) in COVID-19 Year 2, and then decreased to 14.9% (95% CI, 14.9-15.0) in COVID-19 Year 3 (Figure).

Figure. Overall trends in alcohol use prior to, during, and after the COVID-19 pandemic.

Note: * P<0.05 when compared to March 1,2018-February 28,2019 within the same alcohol use category.

Alcohol use trends among subgroups were generally similar to the aforementioned overall trends (ie, the proportion reporting high-risk alcohol use was lowest during COVID-19 Year 1, increased during COVID-19 Year 2, and then decreased during COVID-19 Year 3, but remained comparatively higher than COVID-19 Year 1), but with some notable exceptions (Supplementary Table, available online). Among non-Hispanic whites, African Americans, Asian Pacific Islanders, and Hispanics, women had a lower proportion of high-risk alcohol use during March 2018-February 2019. However, over time and, most notable, following onset of the pandemic, the proportion of women reporting high-risk alcohol use surpassed that of men, and in COVID-19 Year 3, a significantly greater proportion of high-risk alcohol use was reported in women vs men among non-Hispanic whites (16.3% vs 15.3%, P < .01), African Americans (14.6% vs 14.1%, P < .01), and Hispanics (14.5% vs 13.4%, P < .01). When stratified by age groups, the greatest proportion of high-risk alcohol use was observed among young Veterans ages 18-39 years, which was consistent among all race/ethnic groups and persisted throughout the study period. During COVID-19 Year 3, the proportion of Veterans ages 18-39 years who reported high-risk alcohol use ranged from 16.6% in Asian Pacific Islanders to 27.0% among American Indian/Alaska Natives. When evaluating by residence in an urban vs a rural setting, significantly greater proportions of high-risk alcohol use were reported among Veterans in urban vs rural areas among non-Hispanic whites and African Americans, whereas significantly greater proportions of high-risk alcohol use were observed in rural areas among Asian Pacific Islanders and Hispanics (Supplementary Table).

DISCUSSION

Among a national cohort of US Veterans, high-risk alcohol use was lowest in COVID-19 Year 1, peaked during COVID-19 Year 2, and, while it decreased during COVID-19 Year 3, the proportion of Veterans reporting high-risk alcohol use remained higher than the nadir observed in COVID-19 Year 1. These observations seem to suggest that the increase in alcohol consumption immediately following the onset of the pandemic reported in other studies may have been delayed among Veterans,⁸ and that current levels of high-risk alcohol use in Veterans remain alarmingly elevated. From March 2022-February 2023, high-risk alcohol use was reported in nearly 15% of Veterans overall and in over 20% of young Veterans ages 18-39 years. In addition, high-risk alcohol use among female Veterans surpassed male Veterans at the onset of the pandemic, which persisted into the most recent period analyzed.

The greater increase in alcohol consumption in women and young adults during the pandemic has been previously reported, albeit in non-Veteran populations.^15,16 We highlight similar patterns among US Veterans, which emphasizes the need for greater awareness about the consequences of unhealthy alcohol use and interventions aimed specifically at addressing alcohol use disorders in these populations. This is particularly true for Veterans, who have high prevalence of mental health comorbidities and behavioral risk factors associated with high-risk alcohol use. Equally important, these data demonstrate that 3 years after the onset of the pandemic, high-risk alcohol use persists among Veterans, and targeted and effective interventions are urgently needed to mitigate high-risk alcohol use to decrease the risk of alcohol-associated health consequences.

Potential limitations of the current study include the self-reported nature of alcohol use based on AUDIT-C scores, which is subject to recall bias and does not allow detailed quantification of alcohol consumption amounts and patterns. However, AUDIT-C is routinely assessed as part of usual care in the VA, which allowed comprehensive and longitudinal assessment of alcohol use trends using national VA data. While we were not able to link each individual AUDIT-C score to specific clinical encounters and thus, were unable to determine the specific clinical context or clinical location where each AUDIT-C score was assessed, it is likely that the majority of AUDIT-C scores were obtained from the primary care setting. Patients not regularly engaged in care may not have had AUDIT-C scores assessed and documented, and thus, would not have been captured in this analysis, thereby potentially contributing to selection bias. While we categorized our study periods to roughly correspond to the onset of the COVID-19 pandemic and the subsequent 1 to 3 years following the pandemic, it is important to note that fluctuations in COVID-19 disease activity persists among different populations and different geographic regions, which may have affected the trends in alcohol consumption observed. In addition, while we hypothesize that the observed alcohol use trends may be related to changes in alcohol consumption resulting from the COVID-19 pandemic, given the observational nature of this study, we are only able to report on associations and cannot determine causation with certainty, and as such, it is possible there may be other unmeasured factors and confounders that may have influenced alcohol use trends among Veterans.

In conclusion, high-risk alcohol use among US Veterans has increased since the onset of the COVID-19 pandemic, and in the third year following pandemic onset, more than 1 in 7 Veterans reported high-risk alcohol use. Similarly alarming, over 20% of young Veterans ages 18-39 years reported high-risk alcohol use. These data emphasize the urgent need for greater awareness of the dangers of high-risk alcohol use among Veterans, routine assessment of alcohol use, and timely linkage to appropriate resources and treatment for those at risk of alcohol use disorder.

CLINICAL SIGNIFICANCE.

• Veterans were especially vulnerable to increased alcohol consumption following onset of the COVID-19 pandemic.

• High-risk alcohol use among US Veterans reached its lowest point in the first year of the pandemic, but it has since increased, and in the third year following pandemic onset, 15% of Veterans reported high-risk alcohol use.

• Following the pandemic, over 20% of young Veterans ages 18-39 years reported high-risk alcohol use.