Introduction: During the first phase of the coronavirus (COVID-19) pandemic lockdowns in South Africa (SA), both alcohol and tobacco were considered non-essential goods and their sales were initially prohibited and further restricted to certain days and timeframes. This study investigates self-reported changes in alcohol consumption and tobacco smoking behaviour in the general population during the COVID-19 pandemic lockdowns in SA. Methods: A cross-sectional national survey was conducted in October 2021 (before the Omicron wave 4 and while SA was in low-level lockdown) among 3,402 nationally representative respondents (weighted to 39,640,674) aged 18 years and older. Alcohol consumption and tobacco use were assessed from the beginning of the lockdown towards the end of March 2020 until October 2021 using the WHO-AUDIT and the US Centre for Disease Control (CDC) Global Adult Tobacco Survey questionnaires, respectively. Results: Among those that drank alcohol (33.2%), 31.4% were classified as having a drinking problem that could be hazardous or harmful and 18.9% had severe alcohol use disorder during the COVID-19 lockdowns. Twenty-two per cent (22.0%) of those that reported alcohol consumption reported that the COVID-19 pandemic lockdowns changed their alcohol consumption habits, with 38.1% reporting a decreased intake or quitting altogether. Among the one in five respondents (19.2%) who had ever smoked, most reported smoking at the time of the survey (82.6%) with many classified as light smokers (87.8%; ≤10 cigarettes/day). Almost a third (27.2%) of those smoking reported that the COVID-19 pandemic lockdowns had changed their use of tobacco products or vaping, with 60.0% reporting a reduction/quitting tobacco use. Given that sales were restricted this indicates that people could still get hold of tobacco products. Heavy smoking was associated with older age (p = 0.02), those classified as wealthy (p < 0.001), those who started or increased tobacco smoking during the pandemic lockdowns (p = 0.01) and residential provinces (p = 0.04). Conclusion: Given restrictions on the sale of alcohol and tobacco in SA between 27 March and August 17, 2020, during the pandemic, respondents reported an overall decline in alcohol consumption and tobacco use which might suggest that the regulatory restrictive strategies on sales had some effect but may be inadequate, especially during times where individuals are likely to experience high-stress levels. These changes in alcohol consumption and tobacco use were different from what was reported in several European countries, possibly due to differences in the restrictions imposed in SA when compared to these European countries.

© 2023 S. Karger AG, Basel

Introduction

The novel coronavirus disease (COVID-19) has resulted in unprecedented morbidity and mortality across the world [1–3]. Due to such tremendous increases in morbidity and mortality, almost all countries declared restrictions in the first quarter of 2020 as a way to mitigate the pandemic’s effect [4]. Thus, on March 26, 2020, the South African (SA) government started implementing national lockdowns to slow down and contain the spread of COVID-19 across the country [5]. These national lockdowns included travel bans within and across the provinces, closures of schools, universities, non-essential businesses (tourism, restaurants, sporting events, concerts), as well as social contacts among other restrictions [5]. The SA government also introduced total alcohol and tobacco sale restrictions until the end of August 2020, when controlled and coordinated sales were permitted Monday to Thursday [5].

As a result of lockdown-induced restrictions, people worldwide have experienced social isolation, and general fear [6, 7], potentially resulting in negative dysfunctional responses including unhealthy behaviours such as increased alcohol and tobacco consumption [8, 9]. The World Health Organization (WHO) has already warned of the potential future health risk of increased alcohol consumption and tobacco use during the COVID-19 restrictions [4]. This too was observed with previous pandemics (SARS outbreak in 2003, H1N1 influenza, and EBOLA) influencing people to adopt dysfunctional coping mechanisms such as increased alcohol consumption, tobacco, and marijuana use as well as experiencing more mental health issues [6, 10].

In the USA, approximately 60% of adults reported having increased their alcohol intake as a result of the pandemic lockdown as compared to pre-COVID-19, with only 13% reporting a decreased intake [11]. In Germany, 35.5% of adults reported an increase in alcohol consumption during lockdowns with only 21.3% drinking less [12]. The odds of smoking were also identified to have increased during the lockdown in Germany, with almost 46% of adults reporting increased tobacco use due to stress-related issues [12]. Furthermore, increased alcohol consumption and tobacco use have been attributed to restrictions in movement, increased stress, boredom, loneliness, and availability of alcohol in the house [11–13].

In South Africa (SA), a study in 2018 reported that in general, 33% of adults consume alcohol with 43% of these binge drinking [14]. Furthermore, excessive alcohol consumption is associated with the burden of infectious diseases, non-communicable diseases, injury and trauma, and poor maternal and child health in SA [15]. With the COVID-19 pandemic lockdowns, alcohol consumption and tobacco use may have increased along with psychological and mental health issues. However, in SA, alcohol and tobacco sale restrictions were implemented to limit social gatherings as well as relieve hospitals of alcohol-related trauma cases. Furthermore, tobacco restrictions were also implemented to prevent the spread of COVID-19 via cigarette sharing and reduce the number of severe cases of COVID-19 among tobacco users [16]. Therefore, we aimed to investigate the self-reported changes in alcohol consumption and tobacco smoking behaviour in a nationally representative population 14 months after total alcohol and tobacco sale restrictions before the Omicron COVID-19 wave 4 and while SA was in a low-level lockdown. We aimed to answer the following research questions: What were the self-reported changes in alcohol consumption and tobacco smoking behaviour among South African adults 14 months after COVID-19 alcohol and tobacco sale restrictions? Furthermore, what were the changes in alcohol consumption and tobacco smoking behaviour which were related to educational level, employment, and wealth status among other factors? Our results are discussed in the context and differences between SA and Europe to draw parallels between the two.

MethodsStudy Design

This national cross-sectional survey was conducted on 3,402 South African adult participants and was executed on behalf of the researchers by an international market research company (Fig. 1). Questions included the amount of alcohol consumed and the number of cigarettes, e-cigarettes, and vaping done in a day or week as well as an exploration of the impact of COVID-19 on alcohol consumption and tobacco use. The study was conducted in October 2021 and administered in English and SA’s major local languages (IsiXhosa, IsiZulu, Sesotho, Sepedi, Setswana, and Afrikaans).

Fig. 1.

Sample size weighted and projected to South African population 18 years and older.

Recruitment of Participants and Inclusion Criteria

The study participants were recruited from all nine provinces of SA using a 6-phase stratified random probability sampling method. Phase 1, stratification (Fig. 2), was used to select provinces, community size (metropolitan areas; city; large town; small town, a large village, and rural area), and gender and to ensure adequate representation. Phase 2, selection of sampling units (with a population of greater than 500), was randomly selected for six interviews per unit. The geographic information system (GIS) mapping technology was used to determine the starting point for the survey in each sampled unit. From the identified starting point, the first household to be interviewed would be randomly selected and thereafter, interviewers would skip five houses and conduct the next interview on the sixth household. Only adults, 18 years and older, were included in the interviews.

Fig. 2.

Sampling and data collection phases.

Assessment Instrument

The survey included assessments of sociodemographic variables (age, gender, education level, and employment status), wealth index (which was calculated using household assets, with a score of 1 [classified as poor] to 5 [classified as wealthy]) and changes in both alcohol consumption and tobacco use during the COVID-19 pandemic lockdown. The assessments on both alcohol consumption and tobacco use focused on the period from the beginning of the lockdown towards the end of March 2020 until October 2021. These self-reported changes in this period were being considered to the pre-COVID-19 levels of consumption and use. The survey’s exact items/questions were from the US Centre for Disease Control (CDC) Global Adult Tobacco Survey and the WHO Alcohol Use Disorders Test (WHO-AUDIT) [17, 18]. These questionnaires were administered in person (face to face) by the research field workers. The dependent variables for both alcohol consumption and tobacco use were categorised into two groups each as follows: hazardous or harmful alcohol consumption and moderate-severe alcohol use disorder; and light and heavy smoking (Table 1).

Table 1.

Alcohol consumption and tobacco use categorisation

VariableThe instrument used to measure the variableCategorisation/Operational termCategorisation scoresAlcohol consumptionWHO Alcohol Use Disorders Test (WHO-AUDIT)Hazardous or harmful alcohol consumptionA score of between 8 and 15Moderate-severe alcohol use disorderA score of 16 and aboveTobacco useUS Centre for Disease Control (CDC) Global Adult Tobacco SurveyLight smoking10 or fewer cigarettes per dayHeavy smoking11 or more cigarettes per dayData Analyses

Statistical analyses were performed using Stata version 16 (Stata Corp Ltd, Texas, USA). The general characteristics of the study respondents were analysed using descriptive statistics. χ2 with confidence intervals was used to determine the association between the binary scores and the independent variables of interest (socio-demographic characteristics, COVID-19 effect on alcohol consumption, province, and community size). Using simple logistic regression, dependent variables that were significant in χ2 analysis and the independent variables of interest were computed. Odds ratios were used to determine the strength of association between socio-demographic characteristics and provinces with moderate-severe alcohol use disorder and heavy smoking. All the analyses were two-sided, and the p value was highly significant at <0.001 and moderately significant at < 0.05.

ResultsSocio-Demographic and Drinking and Smoking Characteristics

The mean age of the participants was 37.7 years, 52.5% were female, 59.2% were never married, and 66.8% had secondary and/or high school education (Table 2). The largest proportion of participants (57.10%) was employed, with 37.2% not in any employment. In addition, most participants were from Gauteng province (28.92%).

Table 2.

Descriptive statistics of socio-demographic, alcohol consumption, and tobacco smoking

VariablesN = 3,402National weighted (%) [mean (SD)]Socio-demographic characteristicsAge37.7 (12.3)Gender Female52.5 Male47.5Marital status Never married59.2 Married or living with a partner30.7 Divorced or widowed or separated10.1Educational level Primary school or below4.1 Completed secondary and high school66.8 Tertiary29.1Employment status Not employed (including students)37.2 Employed (full-time, part-time, and self-employed)57.1 Retired5.7Wealth index 124.0 219.8 318.8 417.5 5 (wealthiest)19.9Community size Metropolitan area46.2 City or large and small towns25.4 Large village or rural28.4Alcohol consumption statusDo you currently drink alcohol (among the whole sample)? Yes33.2 No66.8Drinking level (alcohol audit scores) among the 33.2% who reported drinking alcohol Low-risk consumption (a score of 1–7)49.7 Hazardous or harmful alcohol consumption (a score 8-14)31.4 Moderate-severe alcohol use disorder (a score of 15 or more)18.9Has the COVID-19 pandemic changed your use of alcohol (among the 33.2% who reported drinking alcohol)? Yes22.0 No78.0How has COVID-19 changed your alcohol usage (among the 22.0% who answered yes to COVID-19 impact)? Increased a lot or started using during9.4 Increased a little14.6 Decreased a little37.9 Decreased a lot or quit during the pandemic38.1Tobacco smoking statusHave you ever smoked (among the whole sample)? Yes19.2 No80.8Have you smoked cigarettes in the past year (among the 19.2%) who reported to have ever smoked)? Have smoked cigarettes in the past year86.1 Currently smoking82.6 Used other forms of tobacco including smokeless and chewable29.6 Used to vape in the last year15.8Light/heavy smoking level (among those who reported to be currently smoking) Light smoking (10 or fewer cigarettes per day)87.8 Heavy smoking (11 or more cigarettes per day)12.2Has the COVID-19 pandemic changed your use of tobacco products or vaping (among those currently smoking)? Yes27.2 No72.8How has COVID-19 changed your smoking usage (among the 27.2% who answered yes to COVID-19 impact on smoking)? Increased a lot or started using during the pandemic11.7 Increased a little17.4 Decreased a little43.1 Decreased a lot or quit during the pandemic27.8

Thirty-three per cent (33.2%) of the respondents reported drinking alcohol, with half of these (50.3%) classified as having hazardous/harmful alcohol consumption or moderate-severe alcohol use disorder according to the alcohol audit scores. Twenty-two per cent (22.0%) of participants reported that COVID-19 pandemic lockdowns changed their alcohol drinking, with 38.1% indicating that their consumption had decreased a lot, or they had quit during the pandemic (between March 2020 and October 2021 and this included the period where alcohol sales were restricted) (Table 2).

Only 19.2% of the participants indicated that they had ever smoked, with 82.6% of those still currently smoking at the time of the survey. Of those currently smoking, 87.8% were light smokers, smoking 10 or fewer cigarettes per day. As a result of the COVID-19 pandemic lockdowns, almost one-third (27.2%) of respondents changed their use of tobacco products or vaping, with over 60% indicating that their smoking has decreased a lot or they had quit during the pandemic and one-third (29.1%) having increased or initiated their tobacco use during the pandemic.

Comparisons of Alcohol Users by Hazardous Alcohol Consumption Categories

Moderate-severe alcohol use disorder (likelihood of alcohol dependence) did not vary by age (p = 0.11), marital status (p = 0.68), educational level (p = 0.17), wealth index (p = 0.75), or community size (p = 0.32). Moderate-severe alcohol use disorder was more frequently observed in men, respondents who were not employed (including students), and those who reside in the Gauteng province (Table 3). Additionally, those with a higher likelihood of alcohol dependence less frequently reported decreasing or stopping alcohol consumption as a result of the pandemic.

Table 3.

Characteristics of participants who reported drinking alcohol by hazardous and moderate-severe drinking levels

Hazardous or harmful alcohol consumption (n = 396)
% [95% CI]Moderate-severe alcohol use disorder (n = 234)
% [95% CI]p valueTotal
% [95% CI]Age 18–24 years old15.3 [11.1–20.7]11.8 [7.9–17.2]0.1114.0 [10.9–17.8] 25–34 years old33.8 [28.5–39.5]35.9 [29.1–43.3]34.6 [30.3–39.1] 35–44 years old26.1 [21.8–30.9]27.1 [21.4–33.6]26.5 [23.0–30.3] 45–54 years old14.0 [10.6–18.2]15.1 [10.7–20.8]14.4 [11.6–17.7] 55–64 years old10.9 [7.3–15.9]7.7 [4.2–13.8]9.7 [7.0–13.4] ≥6502.5 [0.9–6.7]1.0 [0.4–2.6]Gender Female39.4 [33.8–45.3]27.0 [21.1–33.9]0.01*34.8 [30.5–39.2] Male60.6 [54.7–66.2]73.0 [66.1–78.9]65.2 [60.8–69.5]Marital status Never married57.1 [51.3–62.8]54.6 [47.2–61.8]0.6856.2 [51.6–60.6] Married or living with partner36.4 [31.0–42.2]36.9 [30.0–44.4]36.6 [32.3–41.2] Divorced or widowed or separated6.5 [4.1–9.9]8.5 [5.2–13.7]7.2 [5.2–10.0]Educational level Primary school and below3.1 [1.5–6.3]2.5 [1.1–5.5]0.172.9 [1.7–5.0] Secondary and high school67.5 [61.7–72.7]75.6 [68.6–81.3]70.5 [66.1–74.5] Tertiary29.4 [24.4–35.0]22.0 [16.4–28.8]26.6 [22.8–30.9]Employment status Not employed (including students)36.3 [30.7–42.4]24.8 [19.2–31.3]0.03*32.0 [27.8–36.5] Employed (full-time, part-time, and self-employed)61.5 [55.4–67.2]71.5 [64.7–77.5]65.2 [60.6–69.6] Retired2.2 [1.0–4.9]3.7 [1.7–8.0]2.8 [1.6–4.9]Wealth Index 122.8 [17.8–28.6]19.2 [14.0–25.7]0.7521.4 [17.7–25.7] 223.3 [18.7–28.6]20.8 [15.1–28.0]22.4 [18.7–26.6] 317.7 [13.9–22.3]21.4 [16.1–27.9]19.1 [15.9–22.8] 417.3 [13.7–21.6]18.4 [13.7–24.2]17.7 [14.8–21.1] 5 (wealthiest)19.0 [14.9–23.9]20.2 [15.0–26.6]19.4 [16.1–23.2]Alcohol drinking changes due to COVID-19 Decreased/quit75.5 [68.0–81.7]56.6 [46.3–66.4]0.002*68.4 [62.2–74.0] Increased/started24.5 [18.3–32.0]43.4 [33.6–53.7]31.7 [26.0–37.9]Community size Metropolitan area51.0 [45.1–56.8]47.6 [40.5–54.9]0.3249.7 [45.2–54.3] City/large and small towns23.6 [18.7–29.4]30.2 [23.7–37.5]26.1 [22.1–20.5] Large village/rural25.4 [20.4–31.1]22.2 [16.2–29.6]24.2 [20.3–28.6]Provinces Western Cape10.0 [7.3–13.5]21.6 [16.0–28.4]0.03*14.3 [11.5–17.7] Eastern Cape8.3 [5.7–12.0]6.9 [4.0–11.7]7.8 [5.7–10.5] Northern Cape0.4 [0.0–2.6]1.4 [0.3–5.4]0.8 [0.2–2.3] Free State7.2 [4.3–12.0]5.2 [2.7–9.9]6.5 [4.3–9.7] KwaZulu Natal11.7 [8.6–15.6]11.3 [7.6–16.4]11.5 [9.1–14.5] North West4.7 [2.8–7.9]1.5 [0.4–5.0]3.5 [2.2–5.6] Gauteng39.0 [33.6–44.6]35.1 [28.8–42.0]37.5 [33.4–41.9] Mpumalanga6.7 [3.7–11.8]3.8 [1.8–8.0]5.6 [3.5–9.0] Limpopo12.1 [8.6–16.7]13.3 [8.4–20.4]12.5 [9.5–16.3]Comparisons of Tobacco Users by Light and Heavy Smoking

Heavy smoking differed by older age (p = 0.02), wealth index (those classified as wealthy) (p < 0.001), tobacco smoking changes due to COVID-19 lockdowns (p = 0.01) and those residing in Gauteng province (p = 0.04). The reported degree of tobacco uses among smokers did not, however, differ by gender (p = 0.08), marital status (p = 0.10), educational level (p = 0.21), employment status (p = 0.20), or community size (metropolitan area, city of rurality) (p = 0.09) (Table 4). Those who smoked more (heavy smokers) each day less frequently reported decreasing or quitting tobacco as a result of the pandemic.

Table 4.

Characteristics of participants who reported smoking and comparison by light and heavy smoking levels

Light smoker (≥10 cigarettes per day) (n = 504)
% [95% CI]Heavy smoker (≥11 cigarettes per day) (n = 71)
% [95% CI]p valueTotal (n = 575)
% [95% CI]Age18–24 years old14.3 [11.1–18.3]21.2 [11.3–36.1]0.02*15.2 [12.0–19.0]25–34 years old29.9 [25.6–34.6]15.5 [7.2–30.1]28.2 [24.2–32.5]35–44 years old25.5 [21.6–29.7]19.6 [11.9–30.4]24.7 [21.2–28.7]45–54 years old14.7 [11.7–18.3]31.7 [20.9–44.8]16.8 [13.7–20.3]55–64 years old12.9 [8.7–16.5]12.1 [5.1–26.3]12.1 [8.9–16.2]≥653.5 [1.9–6.5]03.1 [1.7–5.7]GenderFemale22.8 [18.9–27.3]34.4 [22.3–49.0]0.0824.2 [20.4–28.6]Male77.2 [72.7–81.1]65.6 [51.0–77.7]75.8 [71.4–79.6]Marital statusNever married53.4 [48.5–58.4]37.8 [25.5–51.8]0.1051.5 [46.9–56.2]Married or living with a partner36.3 [31.7–41.2]46.4 [33.2–60.1]37.6 [33.2–42.2]Divorced or widowed or separated10.2 [7.4–14.0]15.9 [8.1–28.9]10.9 [8.1–14.5]Educational levelPrimary school and below5.4 [3.5–8.1]3.5 [1.1–11.0]0.215.1 [3.5–7.6]Secondary and high school71.3 [66.5–75.7]62.7 [48.5–74.9]70.3 [65.7–74.5]Tertiary23.4 [19.3–28.0]33.8 [22.0–48.1]24.6 [20.7–29.0]Employment statusNot employed (including students)33.3 [28.9–38.1]32,5 [20.3–47.7]0.2033.2 [29.0–37.8]Employed (full-time, part-time, and self-employed)61.4 [56.5–66.0]66.9 [51.8–79.2]62.0 [57.4–66.5]Retired5.3 [3.3–8.4]0.6 [0.0–3.9]4.7 [3.0–7.5]Wealth Index118.6 [14.8–23.0]7.1 [2.3–20.2]<0.0001*17.2 [13.7–21.2]224.9 [21.0–29.3]1.5 [0.2–10.2]22.0 [18.5–26.0]321.6 [17.8–25.8]27.4 [16.7–41.5]22.3 [18.7–26.4]415.7 [12.6–19.4]15.6 [8.9–25.8]15.7 [12.8–19.1]5 (wealthiest)19.2 [15.5–23.7]48.4 [35.0–62.1]22.8 [19.0–27.2]Tobacco smoking changes due to COVID-19Decreased/quit77.0 [68.2–84.0]49.3 [29.2–69.6]0.01*72.9 [64.6–79.9]Increased/started23.0 [16.1–31.9]50.7 [30.4–70.8]27.1 [20.1–35.4]Community sizeMetropolitan area57.4 [52.4–62.4]66.6 [52.5–78.3]0.0958.6 [53.4–63.2]City/large and small towns22.7 [18.6–27.5]26.6 [16.3–40.3]23.2 [19.3–27.6]Large village/rural19.8 [16.0–24.3]6.8 [2.1–19.6]18.2 [14.7–22.3]ProvincesWestern Cape28.2 [23.9–32.9]33.9 [22.6–47.3]0.04*28.9 [24.8–33.3]Eastern Cape9.3 [6.8–12.7]0.9 [0.1–6.4]8.3 [6.0–11.3]Northern Cape1.2 [0.4–3.8]01.0 [0.3–3.4]Free State4.4 [2.6–7.3]1.9 [0.5–0.7]4.1 [2.5–6.7]KwaZulu Natal13.0 [10.1–16.6]11.6 [5.3–23.3]12.8 [10.1–16.2]North West1.6 [0.7–3.5]1.1 [0.3–4.5]1.5 [0.7–3.2]Gauteng29.6 [25.5–34.1]46.5 [33.1–60.4]31.7 [27.6–36.1]Mpumalanga5.7 [3.7–8.9]3.6 [0.8–14.8]5.5 [3.6–8.3]Limpopo7.0 [4.8–10.1]0.6 [0.0–3.9]6.2 [4.2–9.0]Factors Associated with Moderate-Severe Alcohol Use Disorder

Multivariate logistic regression showed that males were more likely to have moderate-severe alcohol use disorder (OR = 1.69, CI: 1.2–2.4). Furthermore, those who started or increased their alcohol drinking due to COVID-19 lockdowns had a higher chance (OR = 2.1, CI: 1.3–3.4) of reporting moderate-severe alcohol use disorder as compared to those who quit or decreased alcohol intake due to COVID-19 lockdowns. Employment status had no predictive effect on moderate-severe alcohol use disorder, employed (OR = 1.4, CI: 0.9–2.0) and retired (OR = 2.2, CI: 0.7–6.3) when compared to those unemployed.

Those in the Eastern Cape (OR = 0.5, CI: 0.2–0.9), KwaZulu Natal (OR = 0.5, CI: 0.2–0.8), North West (OR = 0.2, CI: 0.04–0.6), and Gauteng (OR = 0.5, CI: 0.3–0.8) provinces were found to lower the odds of moderate-severe alcohol use disorder when compared to those in the Western Cape. Although those in the Northern Cape had a higher proportion (above 60%, see Fig. 3) of moderate-severe alcohol use disorder, there was no significant difference when compared to the Western Cape (OR = 1.8, CI: 0.2–20.9). There were also no significant differences between Western Cape and Free State (OR = 0.5, CI: 0.2–1.0) provinces, nor for Mpumalanga (OR = 0.4, CI: 0.2–1.1) and Limpopo (OR = 0.6, CI: 0.3–1.1) provinces.

Fig. 3.

Proportions of moderate-severe alcohol use and heavy smoking by province.

Factors Associat