Abstract
Bars appear to be serving up a most dangerous concoction during the COVID‐19 pandemic, attracting groups of drinkers who are prone to disinhibition and resulting behaviors that can heighten the risk of virus transmission. This provides the context for why bars are among the last businesses to return to normal operations as states reopen their economies — and now among the first to be shuttered when spikes in cases cause some states to pull back.
Bottom Line…
The link between alcohol use and disinhibition lends support to policies restricting operations in bars during the pandemic.
Bars appear to be serving up a most dangerous concoction during the COVID‐19 pandemic, attracting groups of drinkers who are prone to disinhibition and resulting behaviors that can heighten the risk of virus transmission. This provides the context for why bars are among the last businesses to return to normal operations as states reopen their economies — and now among the first to be shuttered when spikes in cases cause some states to pull back.
With socializing over alcohol an integral part of the nation's cultural fabric, few expect bars to lose favor as a gathering place over the long term. But research leaders interviewed by ADAW say there are numerous reasons why it makes sense to think twice about the bar setting for now.
“When people are at least somewhat intoxicated, they cannot pay attention and respond appropriately to all the cues in a situation,” said Kenneth Leonard, Ph.D., director of the Research Institute on Addictions at the University at Buffalo. “They tend to behave in accordance with the most dominant cues,” with alcohol itself being the most salient cue in the bar environment. (Think about the view of bottles lined across the bar area's back wall.)
Leonard said when other cues are present, the problematic drinker will tend not to think about them as deeply as he/she would when sober. “So if someone walks by wearing a mask, instead of thinking, ‘This is important for me, to maintain distance,’ the thought may just be ‘Oh, there goes someone in a mask.’ That's the extent of your thinking about it,” he said.
This often‐cited phenomenon of “alcohol myopia” can therefore prove extremely dangerous in settings where proper distancing among patrons isn't feasible or isn't being enforced. Following his decision late last month to force the reclosing of bars in the state amid a steep increase in COVID‐19 cases, Texas Gov. Greg Abbott told an El Paso news station, “If I could go back and redo anything, it probably would have been to slow down the opening of bars, now seeing in the aftermath of how quickly the coronavirus spread in the bar setting.”
A group of Texas bar owners proceeded to file lawsuits challenging the governor's most recent order, claiming that it unfairly targets bars while businesses such as salons and tattoo parlors have been allowed to remain open.
Transmission risk
A confluence of factors can make bars an obvious location for virus transmission. “We know that as alcohol doses increase, that produces a good amount of disinhibition,” said George Koob, Ph.D., director of the National Institute on Alcohol Abuse and Alcoholism. Alcohol's effects in disabling activity in the brain's frontal cortex can lead to more risk‐taking and more immediate decision‐making on the user's part, Koob said.
When the setting is a crowded bar, this will lead to patrons speaking more loudly and releasing more particles into the air, he said. “You might take off your mask to make your point more clearly,” he said. (A revised order last week from the mayor of Miami‐Dade County, Florida, is prohibiting the playing of loud music in outdoor restaurant spaces, so that diners don't have to shout over the din in order to be heard by those around them.)
Alcohol myopia in the bar setting, Koob said, plays out in drinkers focusing only on their current drink and how to get the next one. “They lose their peripheral attentional mechanisms,” he said, and may not be aware of the behaviors of others around them.
Combine these concerns with the findings of research that has shown an association between alcohol consumption and suppression of immune function (see “Effects on lung, immune function offer warning for drinking in crisis,” ADAW, April 20, https://onlinelibrary.wiley.com/doi/10.1002/adaw.32693), and it is not difficult to understand why bars can be the most favored targets for state leaders' efforts to curb virus spread.
Conversely, alcohol myopia may not be as much of a problem in at‐home settings, where other cues may divert some of the focus from drinking, Leonard said.
Lasting behavior change?
Reports of soaring alcohol sales in the early weeks of the pandemic have given way to an overall decline in sales more recently, but with online sales staying strong. Leonard said he has seen reports that the industry as a whole will have to see a 20% increase from normal sales through the rest of the year in order to recover losses brought on by closed businesses at the height of the pandemic.
How the pandemic might affect individuals' drinking behavior over the long haul remains an open question. Interest in moderation has ebbed and flowed many times throughout history, Leonard said. While there is a current understanding that bars are among the riskiest gathering places, that might not change the public's behavior in the long term. “For a lot of people, bars are their social life,” Leonard said.
There appears to be a number of forces that are both encouraging more drinking in social settings and offering nondrinking alternatives. Koob said that while alcohol served at supermarkets and in yoga studios has become more common, at the same time there has been a growing interest in participating in dry months or socializing in bar‐like settings that serve mocktails rather than alcohol.
“What was beginning to change before the pandemic was people having a choice, where there is no stigma about not having a drink,” Koob said.
Richard Saitz, M.D., M.P.H., chair of the Department of Community Health Sciences at the Boston University School of Medicine, believes the same sense of economic despair that contributed to the opioid crisis has only increased the risk of alcohol misuse during the pandemic. “It's a pretty good guess that some people who might not otherwise have been drinking may stick with it because of all the things that have happened to them during the pandemic,” Saitz said.
While it is likely that many will eventually return to bars, Saitz said, another option for some might involve ordering alcohol and having it delivered to one's home, if that can be done rapidly and efficiently. Michigan legislators have moved in this direction to help bars and restaurants adversely affected by the crisis, allowing these establishments to deliver alcohol in sealed containers with no more than one gallon of liquid. This authority is scheduled to remain in effect through 2025.