Summary:

• Alcohol use may increase the risk of COVID-19 infection and of its severe complications while also causing other medical and social problems that burden healthcare and other services.

• Alcohol increases COVID-19 transmission by reducing social inhibitions even at low consumption levels, and causing severe impairment at higher levels, thus disrupting preventative strategies, such as social distancing and hand hygiene.

• Many complications from heavy alcohol use are themselves risk factors for more serious outcomes from COVID-19 infection (e.g. diabetes, obesity, cardiovascular disease).

• Alcohol use, especially heavy use, can compromise immune system responses and also increase susceptibility to serious respiratory illnesses.

• Alcohol-related problems consume substantial health care resources; during COVID-19 strong alcohol control policies could relieve these overstretched services by reducing both alcohol- and COVIDrelated healthcare demand.

• In high income countries, surveys tend to show that more people increased than reduced drinking during the early COVID-19 lockdowns, while total sales and consumption have mostly decreased in low income countries. Local factors and government policies on alcohol availability are key. In Sweden, consumption was reduced by 7% during March and April2020 because increased retail sales were more than offset by reduced travelers’ imports.

• Domestic violence has increased in many places during the pandemic, a problem in which alcohol use is often implicated.

• Traffic crashes decreased in most countries due to reduced travel.

• COVID-19-related isolation, boredom, stress and depression during the pandemic can be worsened by alcohol consumption; these same factors may also lead to excessive alcohol consumption.

• Many governments have exempted off-trade alcohol outlets and alcohol manufacturers from lockdown conditions, designating these as essential services, decisions that, in many countries, have been influenced by alcohol industry lobbying.

• Major regulatory changes or concessions (e.g., liberalizing home delivery of alcohol) will be difficult to reverse and are therefore likely to persist after the pandemic.

• The following public health policies are recommended for pandemics: - suspend alcohol service at sports arenas and large events; - prohibit alcohol consumption in public places such as parks and beaches; - restrict drinking at high-risk on-trade settings such as bars and nightclubs; - impose limits on home delivery, if permitted at all; - make clinical and treatment provisions for people experiencing all types of alcohol-related problems, including dependence; - increase access to mental health services, including online services.

• Health authorities should advise individuals at high-risk for infection or serious complications to reduce or avoid alcohol use (e.g., elderly, overweight, diabetic, smokers, people with respiratory disease, cancer, or cardiovascular disease).

• Given the strong inter-relationship between alcohol and COVID-19, alcohol policies should be maintained or strengthened during the pandemic, not relaxed. • Effective policies, including those to reduce physical availability of alcohol and increase its price through increased alcohol taxes and minimum prices, could help limit viral spread, reduce burden on health services and raise much needed extra government revenue.