Change in alcohol consumption during the Covid-19 pandemic and associations with mental health and financial hardship: results from a survey of Wisconsin patients with cancer.

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Published in final edited form as: J Cancer Surviv. 2023 Nov 28;19(3):754–765. doi: 10.1007/s11764-023-01502-1 Change in alcohol consumption during the Covid-19 pandemic and associations with mental health and financial hardship: results from a survey of Wisconsin patients with cancer Tom Lawler a, * , Shaneda Warren Andersen a, b , Amy Trentham-Dietz a, b , Ajay K Sethi b , Amye J Tevaarwerk c , Kristen M C Malecki b, d , Kristin Litzelman a, e , Priyanka A Pophali f , Ronald E Gangnon a, b, g , John M Hampton a , Kristine Kwekkeboom a, h , Noelle K LoConte a, i Author information Article notes Copyright and License information a University of Wisconsin Carbone Cancer Center, Madison, WI b Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI c Mayo Clinic Comprehensive Cancer Center, Rochester, MN d Division of Environmental and Occupational Health Sciences, School of Public Health, University of Illinois Chicago, Chicago, IL e School of Human Ecology, University of Wisconsin-Madison, Madison, WI f Division of Hematology, Medical Oncology and Palliative Care, University of Wisconsin Carbone Cancer Center, Madison, WI g Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI h School of Nursing, University of Wisconsin-Madison, Madison, WI i Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI Authorship contributions: Thomas Lawler conceptualization, methodology, formal analysis, writing – original draft, writing – review & editing, visualization : Shaneda Warren Andersen conceptualization, writing – review & editing, visualization : Amy Trentham-Dietz conceptualization, methodology, writing – review & editing, visualization, resources, supervision, funding acquisition, investigation, data curation : Ajay Sethi conceptualization, writing – review & editing : Amye Tevarrwerk conceptualization, writing – review & editing : Kristen Malecki conceptualization, writing – review & editing : Kristin Litzelman conceptualization, writing – review & editing : Priyanka Pophali conceptualization, writing – review & editing : Ronald Gangnon writing – review & editing, visualization : John Hampton writing – review & editing : Kris Kwekkeboom conceptualization, writing – review & editing : Noelle Loconte conceptualization, writing – review & editing * Corresponding author: Thomas Lawler, RD, PhD, Cancer Researcher, Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, tlawler2@wisc.edu , (608) 265-9606 Issue date 2025 Jun. PMC Copyright notice PMCID: PMC11130075  NIHMSID: NIHMS1968144  PMID: 38017319 The publisher's version of this article is available at J Cancer Surviv Abstract Purpose: Alcohol consumption increases health risks for patients with cancer. The Covid-19 pandemic may have affected drinking habits for these individuals. We surveyed patients with cancer to examine whether changes in drinking habits were related to mental health or financial effects of the pandemic. Methods: From October 2020 to April 2021, adult patients (age 18–80 years at diagnosis) treated for cancer in southcentral Wisconsin were invited to complete a survey. Age-adjusted percentages for history of anxiety or depression, emotional distress, and financial impacts of Covid-19 overall and by change in alcohol consumption (non-drinker, stable, decreased, or increased) were obtained via logistic regression. Results: In total, 1,875 patients were included in the analysis (median age 64, range 19–87 years), including 9% who increased and 23% who decreased drinking. Compared to stable drinkers (32% of sample), a higher proportion of participants who increased drinking alcohol also reported anxiety or depression (45% vs. 26%), moderate to severe emotional distress (61% vs. 37%) and viewing Covid-19 as a threat to their community (67% vs. 55%). Decreased (vs stable) drinking was associated with higher prevalence of depression or anxiety diagnosis, emotional distress, and negative financial impacts of the pandemic. Compared to non-drinkers (36% of sample), participants who increased drinking were more likely to report emotional distress (61% vs. 48%). Conclusions: Patients with cancer from Wisconsin who changed their alcohol consumption during the Covid-19 pandemic were more likely to report poor mental health including anxiety, depression, and emotional distress than persons whose alcohol consumption was stable. Implications for cancer survivors: Clinicians working with cancer survivors should be aware of the link between poor mental health and increased alcohol consumption and be prepared to offer guidance or referrals to counseling, as needed. Keywords: Covid-19, alcohol, cancer, mental health, depression, anxiety Introduction After the start of the Coronavirus 2019 (Covid-19) pandemic in February 2020, governments around the world implemented non-pharmaceutical interventions such as stay-at-home orders, the closure of schools and non-essential businesses, mask use, and quarantines to mitigate the spread of severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) and reduce the burden of illness on hospitals. Research studies subsequently reported that social isolation, emotional distress, anxiety, and lost income related to the pandemic may have affected patterns of alcohol consumption in individuals subjected to lockdowns[ 1 ]. Survey studies, in particular, indicated that approximately 10–40% of respondents self-reported increasing their alcohol consumption since the onset of the pandemic[ 2 – 11 ]. Notably, increased pandemic-related alcohol consumption has serious implications for public health including for patients with cancer, as higher alcohol consumption is linked to negative effects on cancer prognosis and impaired therapeutic efficacy[ 12 , 13 ]. While previous research has shown that increased alcohol consumption during the Covid-19 pandemic was related to multiple psychosocial factors including depression, anxiety, and emotional distress[ 1 , 3 , 9 , 11 , 14 – 21 ], data are limited from individuals diagnosed with cancer, a clinical population for whom increased drinking warrants particular concern. In the United States (US), there are approximately 17 million individuals living with a cancer diagnosis[ 22 ], and heavy alcohol consumption by patients with cancer is related to higher risk for relapse, distant metastasis, and mortality[ 12 , 13 ]. Heavy alcohol consumption also increases susceptibility to severe SARS CoV-2 infection[ 23 , 24 ]. Little information is available regarding how patterns of alcohol consumption changed during the Covid-19 pandemic for patients with cancer, and what psychosocial factors were related to increased alcohol use in this high-risk population. Although the Covid-19 pandemic and accompanying mitigation interventions have since receded, identifying psychosocial factors related to increased alcohol consumption during a global pandemic may be useful to inform future public health interventions and to identify groups at risk for problematic drinking. To address this gap, we analyzed cross-sectional data from a survey of adult patients with cancer from Wisconsin, a state with high heavy and binge alcohol consumption[ 25 ]. This survey was completed during the Covid-19 pandemic and was designed to investigate the effect of the pandemic on the health of patients with cancer in Wisconsin. We hypothesized that self-reported increased alcohol consumption during the pandemic would be related to emotional distress, history of anxiety or depression, and negative financial effects of the Covid-19 pandemic. Materials and Methods Study sample This research study was approved by the University of Wisconsin Health Science Institutional Review Board. Eligible participants were adults (18–80 years at cancer diagnosis) who received healthcare for cancer diagnosis or treatment at a University of Wisconsin Carbone Cancer Center (UWCCC) clinic between November 1, 2019 and June 30, 2020 and had a valid residential address. Identified through a search of electronic health records, patients were eligible regardless of cancer type, treatment history, tumor stage, and time since first diagnosis. In total, 2,961 patients were invited to participate in the study; 984 patients refused participation and 24 responded that they were too ill to participate. Surveys were completed from October 2020 to April 2021, and were returned by 1,953 participants, comprising 66% of the eligible sample. For this analysis, participants who met any of the following criteria were excluded: only diagnosed with non-melanoma skin cancer (N=11), skipped the question asking if they had ever been diagnosed with cancer (N=7), skipped the question asking how their alcohol consumption had changed due to the pandemic (N=56), or did not report their age at survey completion (N = 5). A total of 1,875 surveys were included in the final analysis. All participants provided informed, written consent, and all research activities conformed to the Declaration of Helsinki. Survey design and assessment of alcohol consumption The survey questionnaire included 80 questions covering the following sections: (A) Cancer Diagnosis and Treatment, (B) Covid-19, (C) Impact of Covid-19 on Health and Healthcare, (D) General Health Status, (E) Lifestyle and Health Behaviors, (F) Other Impacts of COVID-19, and (G) Demographics. In section E (Lifestyle and Health Behaviors), participants were asked to provide the number of (1) glasses of wine or wine coolers (size of a regular can of soda), (2) glasses, bottles, or cans of beer (size of a regular can of soda), and (3) drinks of hard liquor (1.5-ounce shots) they usually consume each week. They were also asked to self-report change in alcohol consumption since the onset of the Covid-19 pandemic, with the following options: “A lot more”, “A little more”, “About the same”, “A little lower”, “Much lower”, and “I don’t drink alcohol now, and I didn’t drink alcohol before Covid-19”. For the analysis, self-reported increased alcohol consumption since the onset of Covid-19 pandemic was defined as “a little more” or “a lot more”, while decreased alcohol consumption included “a little lower” and “a lot lower”. Participants were also asked to describe their primary motivation(s) for change in alcohol consumption, with options including “concerns related to Covid-19”, “concerns related to cancer”, and “other”. Participants who reported “other” were asked to describe their primary motivation, with responses manually grouped into the following categories: “other concerns related to health”, “lockdown restrictions”, “sadness, stress, depression, or anxiety”, “boredom, more time at home”, “concerns about politics or current events”, or “do not care for alcohol, or lower tolerance”. Participants also completed the Cut down, Annoyed, Guilty, and Eye-opener (CAGE) screening tool, a validated set of four yes/no questions to identify potential alcohol abuse[ 26 ]. Participants were given one point for each question to which they responded “yes” including whether they ever felt the need to cut down on their drinking (C), whether they felt annoyed when others criticized their drinking (A), whether they felt guilty about their drinking (G), and whether they ever needed a morning “eye-opener” to steady their nerves or treat a hangover (E). A score of two or more points on the CAGE screener is considered clinically significant[ 26 ]. Assessment of mental health, financial status, and pessimistic attitudes about Covid-19 In the ‘General Health Status’ component of the survey, participants were queried regarding whether they had ever been told by a doctor or healthcare professional that they had depression or anxiety. They were also asked to rate the level of distress they had been experiencing in the past week on a scale from 0 (no distress) to 10 (extreme distress), utilizing the National Comprehensive Cancer Network (NCCN) ‘distress thermometer’[ 27 ]. A score of ≥ 4 was defined as ‘moderate to severe distress’, as this is an established threshold to identify clinically significant emotional distress in patients with cancer[ 28 ]. Regarding ‘Other Impacts of Covid-19’, participants were further asked to report whether the Covid-19 pandemic had impacted them financially and whether they had lost job-related income as a result, on a scale from 1 (“Not true of me at all”) to 7 (“Very true of me”)[ 29 ]. A response of ≥ 5 out of 7 was taken to indicate strong agreement. Pessimistic attitudes concerning the Covid-19 pandemic were assessed utilizing a five level Likert scale from “Strongly agree” to “Strongly disagree”, with participants asked to rate their agreement with the following questions: “Covid-19 is a threat to my community”, and “Covid-19 is a threat to my household”[ 29 ]. Statistical analysis Participant demographic characteristics, including age, race, ethnicity, education, income, and most recent cancer type, were tabulated by change in alcohol consumption, with adjustment for age at survey completion. Logistic regression analysis was utilized to investigate the prevalence of anxiety or depression, emotional distress, negative financial effects of the Covid-19 pandemic, lost job income from the pandemic, and pessimistic attitudes about SARS CoV-2 infection by self-reported change in alcohol consumption since the onset of the pandemic (“No drinking”, “Stable drinking”, “Decreased drinking”, or “Increased drinking”). For the ‘Increased’ and ‘Decreased’ drinking categories, data are presented as the percentage difference for each variable of interest relative to the reference category, with 95% confidence interval. Separate models were run utilizing stable drinkers and non-drinkers as the reference category. All models were adjusted for age at survey completion (18–39, 40–59, 60–69, or 70–80 years). Associations are reported for the full sample, as well as stratified by sex and age (<60 years, ≥60 years). All analyses were completed with SAS version 9.4 ( SAS Inc., Cary, NC ). Results Characteristics of 1,875 participants who completed the survey (median age [range]: 64 [19–87] years at survey completion) are displayed in Table 1 . The sample was predominantly female (57%), White (94%), non-Hispanic (98%), with 78% completing at least some college education. There were 598 participants who reported stable alcohol use since the onset of the Covid-19 pandemic (32%), 436 who reported decreased consumption (23%), 171 with increased consumption (9%), and 670 who reported not drinking alcohol before or during the pandemic (36%). Table 1: Demographic characteristics of 1,875 patients with cancer according to reported change in alcohol consumption since the onset of the Covid-19 pandemic a Characteristic Drinking level compared to pre-Covid-19 Full sample (N = 1,875) Non-drinker (N = 670) Stable drinkers (N = 598) Decreased drinking (N = 436) Increased drinking (N = 171) Age at survey completion (years) 18–39 99 (5%) 28 (4%) 26 (4%) 29 (7%) 16 (9%) 40–59 539 (29%) 178 (27%) 178 (30%) 119 (27%) 64 (37%) 60–69 698 (37%) 250 (37%) 219 (37%) 169 (39%) 60 (35%) ≥ 70 539 (29%) 214 (32%) 175 (29%) 119 (27%) 31 (18%) Sex b Male 800 (43%) 260 (39%) 275 (46%) 201 (46%) 64 (39%) Female 1066 (57%) 406 (61%) 320 (54%) 234 (54%) 106 (61%) Race and ethnicity b White c 1718 (94%) 591 (92%) 558 (95%) 410 (95%) 159 (96%) Black/African American c 27 (1%) 12 (2%) 7 (1%) 5 (1%) 3 (2%) Asian/Pacific Islander c 22 (1%) 11 (2%) 7 (1%) 3 (1%) 1 (0%) Hispanic (any race) 29 (2%) 15 (2%) 8 (1%) 4 (1%) 2 (1%) Other or multiracial c 27 (1%) 10 (2%) 7 (1%) 8 (2%) 2 (1%) Education b High school/GED or less 406 (22%) 185 (27%) 114 (19%) 94 (22%) 13 (8%) Some college or associate’s degree 611 (33%) 227 (35%) 184 (31%) 153 (35%) 47 (27%) Bachelor’s degree 431 (23%) 114 (17%) 159 (27%) 106 (24%) 52 (30%) Graduate or professional degree 414 (22%) 138 (21%) 136 (23%) 82 (19%) 58 (35%) Annual household income b <$20,000 112 (7%) 62 (12%) 17 (3%) 26 (7%) 7 (5%) $20,000–$49,999 339 (22%) 145 (28%) 94 (18%) 80 (22%) 20 (14%) $50,000–$99,999 580 (38%) 190 (37%) 203 (40%) 132 (36%) 55 (36%) ≥$100,000 515 (33%) 124 (24%) 192 (38%) 129 (35%) 70 (45%) Most recent cancer diagnosis b Breast 361 (20%) 123 (19%) 145 (25%) 95 (23%) 56 (33%) Hematological cancers d 77 (4%) 23 (4%) 97 (16%) 90 (21%) 27 (15%) Female reproductive cancers e 103 (6%) 44 (7%) 86 (15%) 45 (11%) 27 (15%) Prostate 242 (13%) 77 (11%) 97 (16%) 45 (10%) 23 (17%) Lung 258 (14%) 100 (15%) 26 (4%) 29 (7%) 4 (3%) Colorectal 355 (19%) 141 (22%) 29 (5%) 19 (5%) 6 (3%) Other f 438 (24%) 142 (22%) 111 (19%) 100 (24%) 27 (15%) Time since most recent diagnosis b <1 year 341 (20%) 126 (21%) 94 (17%) 96 (24%) 25 (15%) 1 year 895 (52%) 304 (50%) 293 (52%) 214 (54%) 84 (52%) 2 years 301 (17%) 103 (17%) 114 (21%) 52 (13%) 32 (19%) ≥3 years 186 (11%) 74 (12%) 57 (10%) 31 (8%) 24 (14%) Current cancer treatment b Medication or chemotherapy at home 464 (25%) 166 (25%) 142 (24%) 117 (27%) 39 (22%) Chemotherapy by IV at clinic 255 (14%) 107 (16%) 53 (9%) 81 (18%) 14 (8%) Radiation 108 (6%) 38 (6%) 29 (5%) 33 (7%) 8 (5%) Recovering from surgery 124 (7%) 40 (6%) 37 (6%) 35 (8%) 12 (7%) Other 38 (2%) 22 (3%) 4 (1%) 9 (2%) 3 (2%) None 943 (50%) 324 (48%) 332 (56%) 195 (45%) 92 (53%) Change in physical activity since onset of pandemic b Decreased 1098 (59%) 415 (62%) 302 (51%) 272 (63%) 109 (64%) Stable or increased 766 (41%) 250 (38%) 295 (49%) 160 (37%) 61 (36%) Current alcoholic drink consumption Mean number of drinks per week (range) 0.4 (0–10) 0 (0–0.2) 0.7 (0–10.0) 0.4 (0–4.1) 1.3 (0–6.0) Open in a new tab a Data presented as N (%), standardized for age. b Covariates contain missing data (9–329 observations) c Non-Hispanic only d Hematologic cancer include leukemia and lymphoma. e Female reproductive cancers include vulvar, vaginal, cervical, endometrial, uterine, ovarian, and fallopian. f Other cancer types with less than 50 survey responses including kidney, melanoma, and others. Respondents who increased their alcohol consumption were more likely to be less than 60 years old, female, with a graduate degree and income ≥$100,000/year. Participants who were non-drinkers or who decreased their alcohol consumption were more likely to be currently receiving chemotherapy at the clinic. 34% of the sample reported a diagnosis of depression or anxiety, while 43% reported moderate to severe distress in the previous week, and 21% reported strong agreement that they had experienced negative financial effects of the Covid-19 pandemic ( Supplementary Table S1 ). 15% of participants indicated strong agreement that they had lost job income because of the pandemic. Compared to male respondents, a higher proportion of female respondents reported depression or anxiety, moderate to severe distress, or negative financial impacts of the Covid-19 pandemic ( Supplementary Table S1 ). Likewise, a higher proportion of younger adults (age <60) reported poor mental health and negative financial impacts of the pandemic compared to older adults ( Supplementary Table S2 ). For participants who decreased their drinking, the primary self-reported motivations for change were concerns about cancer (54% [95% CI: 49–60%]), other health or medication concerns (9% [7–13%]), and fewer opportunities for social drinking due to lockdown restrictions (8% [5–14%]) ( Figure 1 ). For participants who increased their drinking, the primary motivations were boredom or more time at home due to lockdown restrictions (30% [23–39%]), concerns related to Covid-19 (23% [16–30%]), and concerns related to cancer (21% [15–28%]). Figure 1: Open in a new tab Self-reported primary motivation for change in alcohol consumption during the Covid-19 pandemic for survey respondents who reported either increased or decreased alcohol consumption since the onset of Covid-19 (N = 607) a a Data reported as the percentage with 95% confidence intervals. Categories with less than 25 responses for the full sample are suppressed. The categorization of responses varies according to alcohol consumption Compared to participants with stable alcohol consumption, a higher proportion of respondents who increased their drinking after the pandemic onset reported a depression or anxiety diagnosis (45% [95% CI: 37–43%] vs. 26% [22–30%] respectively) and moderate to severe distress in the previous week (61% [53–68%] vs. 37% [33–42%], respectively), with larger differences for women compared to men and for older adults (age ≥60 years) compared to younger adults (distress only) ( Table 2 , Supplementary Table S3 ). For older adults only, those who increased their drinking were more likely to report negative financial impacts from the pandemic compared to stable drinkers (22% [15–31%] vs. 11% [9–15%], respectively). Participants who increased their drinking were also more likely to be flagged by the CAGE screening instrument for problematic drinking. For participants who decreased their drinking, a higher percentage of patients reported an anxiety or depression diagnosis compared to stable drinkers (36% [31–42%] vs. 26% [22–30%], respectively), as well as moderate to severe distress in the previous week (48% [43–54%] vs. 37% [33–42%], respectively) ( Table 2 , Supplementary Table S3 ), and negative financial effects of the pandemic (24% [20–28%] vs. 16% [13–20%], respectively). Table 2: Proportion of surveyed participants who reported poor mental health, negative effects of the Covid-19 pandemic on finances, and perception of SARS CoV-2 as a significant threat to household and community, for participants who self-reported increased or decreased alcohol consumption compared to participants with stable drinking a . Survey Responses Stable drinking % (95% CI) Reference Decreased drinking β (95% CI) %Diff. vs. stable drinkers Increased drinking β (95% CI) %Diff. vs. stable drinkers Full sample (N = 1,205) Depression or anxiety (% yes) 26 (22–30) +11 (4–17) +19 (10–27) Moderate to severe distress in past week (% yes) b 37 (33–42) +11 (5–18) +24 (15–32) Covid-19 negatively impacted finances (% yes) c 16 (13–20) +7 (2–12) +5 (−1–12) Lost job income from Covid-19 (% yes) d 13 (10–16) +4 (−1–8) +0 (−5–6) View Covid-19 as threat to community (% yes) 55 (51–60) +6 (0–12) +11 (3–20) View Covid-19 as threat to household (% yes) 15 (12–18) −4 (−8–1) +1 (−5–7) CAGE screening score ≥ 2 (% yes) 2 (1–3) +1 (−1–3) +18 (11–24) Males (N = 540) Depression or anxiety (% yes) 21 (16–27) +9 (0–18) +14 (0–27) Moderate to severe distress in past week (% yes) b 34 (27–41) +14 (5–23) +12 (−1–26) Covid-19 negatively impacted finances (% yes) c 14 (9–19) +11 (3–18) +4 (−6–14) Lost job income from Covid-19 (% yes) d 11 (7–16) +4 (−2–11) +2 (−7–11) View Covid-19 as threat to community (% yes) 53 (45–60) +5 (−4–14) +12 (−1–26) View Covid-19 as threat to household (% yes) 16 (11–21) −5 (−11–1) −1 (−11–9) CAGE screening score ≥ 2 (% yes) 2 (1–5) 0 (−2–3) +22 (11–33) Females (N = 660) Depression or anxiety (% yes) 30 (25–36) +11 (3–20) +19 (8–31) Moderate to severe distress in past week (% yes) b 40 (34–46) +9 (0–18) +30 (20–41) Covid-19 negatively impacted finances (% yes) c 19 (15–24) +5 (−2–12) +5 (−4–14) Lost job income from Covid-19 (% yes) d 15 (11–20) +4 (−3–10) −1 (−8–6) View Covid-19 as threat to community (% yes) 58 (52–64) +6 (−2–14) +9 (−2–20) View Covid-19 as threat to household (% yes) 14 (10–19) −2 (−8–3) +1 (−6–9) CAGE screening score ≥ 2 (% yes) 2 (1–4) +1 (−1–4) +14 (6–22) Age < 60 (N = 432) Depression or anxiety (% yes) 32 (25–40) +12 (2–23) +18 (5–31) Moderate to severe distress in past week (% yes) b 46 (38–54) +9 (−2–19) +15 (3–28) Covid-19 negatively impacted finances (% yes) c 24 (18–31) +7 (−2–17) −2 (−12–9) Lost job income from Covid-19 (% yes) d 17 (12–24) +6 (−2–14) −4 (−13–4) View Covid-19 as threat to community (% yes) 49 (41–57) +13 (2–23) +12 (−1–24) View Covid-19 as threat to household (% yes) 13 (9–20) −1 (−8–6) +1 (−8–10) CAGE screening score ≥ 2 (% yes) 2 (1–5) +3 (−1–6) +14 (5–22) Age ≥ 60 (N = 773) Depression or anxiety (% yes) 21 (17–25) +9 (2–16) +18 (7–30) Moderate to severe distress in past week (% yes) b 29 (25–34) +12 (5–20) +29 (18–41) Covid-19 negatively impacted finances (% yes) c 11 (9–15) +7 (1–12) +11 (2–19) Lost job income from Covid-19 (% yes) d 10 (7–13) +2 (−3–7) +4 (−3–12) View Covid-19 as threat to community (% yes) 60 (55–64) +2 (−5–10) +12 (2–23) View Covid-19 as threat to household (% yes) 16 (12–20) −5 (−10–0) +1 (−7–10) CAGE screening score ≥ 2 (% yes) 2 (1–4) 0 (−2–2) +21 (12–30) Open in a new tab a Data presented as percentages with 95% confidence intervals, adjusted for age. b Defined as score ≥ 4 out of 10 on the National Comprehensive Cancer Network Distress Thermometer (see reference 29 ) c Defined as strong agreement (≥ 5 out of 7) with the statement that “Covid-19 has negatively impacted me from a financial point of view”. d Defined as strong agreement (≥ 5 out of 7) with the statement that “I have lost job income due to the Covid-19 pandemic”. Abbreviations: CAGE – Need to cut-down on drinking (C), Annoyed when people criticize your drinking (A), Guilty about drinking (G), Eye-opener required to wake up or treat hangover (E) Compared to participants who did not drink before or during the pandemic, a higher proportion of participants who increased their drinking reported moderate to severe distress in the previous week (61% [53–68%] vs. 48% [44–53%], respectively), although this association was only observed for female participants and older adults ( Table 3 , Supplementary Table S3 ). No strong associations were observed with non-drinkers as the reference group for depression or anxiety diagnosis, negative financial impacts of Covid-19, or lost job income. Participants who decreased their alcohol consumption were more likely to report lost job income from Covid-19 compared to non-drinkers (17% [13–21%] vs. 12% [9–15%], respectively), while no strong differences were observed for other variables. Table 3: Proportion of surveyed participants who reported poor mental health, negative effects of the Covid-19 pandemic on finances, and perception of SARS CoV-2 as a significant threat to household and community, for participants who self-reported increased or decreased alcohol consumption compared to participants who did not drink before or during Covid-19 a . Survey Responses Non-drinkers % (95% CI) Reference Decreased drinking β (95% CI) %Diff. vs. non-drinkers Increased drinking β (95% CI) %Diff. vs. non-drinkers Full sample (N = 1,277) Depression or anxiety (% yes) 41 (36–45) −4 (−11–2) +4 (−5–13) Moderate to severe distress in past week (% yes) b 48 (44–53) 0 (−6–6) +12 (4–21) Covid-19 negatively impacted finances (% yes) c 22 (18–26) +2 (−3–7) 0 (−7–7) Lost job income from Covid-19 (% yes) d 12 (9–15) +5 (1–9) +1 (−4–7) View Covid-19 as threat to community (% yes) 59 (54–63) +3 (−3–9) +8 (0–16) View Covid-19 as threat to household (% yes) 17 (14–21) −6 (−10–−2) −1 (−8–5) Males (N = 525) Depression or anxiety (% yes) 32 (25–39) −2 (−12–7) +3 (−12–17) Moderate to severe distress in past week (% yes) b 47 (40–54) +1 (−8–10) −1 (−15–13) Covid-19 negatively impacted finances (% yes) c 20 (15–26) +4 (−4–12) −3 (−13–8) Lost job income from Covid-19 (% yes) d 11 (7–16) +4 (−2–11) +2 (−7–11) View Covid-19 as threat to community (% yes) 54 (46–61) +4 (−5–13) +11 (−2–25) View Covid-19 as threat to household (% yes) 18 (13–24) −7 (−14–−1) −3 (−13–7) Females (N = 746) Depression or anxiety (% yes) 46 (40–51) −4 (−12–5) +4 (−7–15) Moderate to severe distress in past week (% yes) b 49 (43–54) 0 (−8–8) +21 (11–31) Covid-19 negatively impacted finances (% yes) c 23 (18–28) +1 (−6–8) +2 (−7–11) Lost job income from Covid-19 (% yes) d 12 (9–16) +6 (0–12) +1 (−6–8) View Covid-19 as threat to community (% yes) 62 (56–67) +2 (−6–10) +5 (−5–16) View Covid-19 as threat to household (% yes) 16 (12–21) −4 (−10–1) 0 (−8–7) Age < 60 (N = 434) Depression or anxiety (% yes) 47 (39–55) −2 (−14–9) +4 (−10–17) Moderate to severe distress in past week (% yes) b 60 (52–67) −5 (−15–6) +2 (−11–14) Covid-19 negatively impacted finances (% yes) c 25 (19–33) +6 (−3–15) −3 (−14–8) Lost job income from Covid-19 (% yes) d 16 (11–23) +7 (−1–16) −3 (−12–5) View Covid-19 as threat to community (% yes) 59 (51–67) +3 (−7–13) +1 (−11–14) View Covid-19 as threat to household (% yes) 18 (12–25) −5 (−13–2) −3 (−13–6) Age ≥ 60 (N = 843) Depression or anxiety (% yes) 35 (30–40) −5 (−12–2) +4 (−7–16) Moderate to severe distress in past week (% yes) b 39 (34–43) +3 (−5–10) +20 (9–31) Covid-19 negatively impacted finances (% yes) c 18 (15–22) 0 (−6–6) +4 (−5–13) Lost job income from Covid-19 (% yes) d 9 (7–12) +3 (−1–8) +5 (−2–13) View Covid-19 as threat to community (% yes) 59 (55–64) +2 (−5–10) +13 (2–23) View Covid-19 as threat to household (% yes) 17 (14–21) −6 (−11–−1) 0 (−8–9) Open in a new tab a Data presented as percentages with 95% confidence intervals, adjusted for age. b Defined as score ≥ 4 out of 10 on the National Comprehensive Cancer Network Distress Thermometer (see reference 29 ) c Defined as strong agreement (≥ 5 out of 7) with the statement that “Covid-19 has negatively impacted me from a financial point of view”. d Defined as strong agreement (≥ 5 out of 7) with the statement that “I have lost job income due to the Covid-19 pandemic”. Abbreviations: CAGE – Need to cut-down on drinking (C), Annoyed when people criticize your drinking (A), Guilty about drinking (G), Eye-opener required to wake up or treat hangover (E) The mean number of alcoholic drinks consumed per day was not significantly associated with depression or anxiety diagnosis, moderate to severe distress, negative financial impacts of Covid-19, lost job income from Covid-19, or views of Covid-19 as a threat to a participant’s community or household ( Supplementary Table S4 ). Discussion In this study of patients with cancer from Wisconsin, both self-reported increased and decreased alcohol consumption during the Covid-19 pandemic were positively associated with a previous diagnosis of depression or anxiety, moderate to severe distress, and pessimistic attitudes about SARS CoV-2 infection compared to participants whose alcohol consumption was stable. This study adds to a body of evidence linking pandemic-related stress to changes in alcohol consumption and demonstrates that these findings may generalize to patients with cancer. Notably, continued susceptibility to Covid-19 infection and mortality for vulnerable populations, including patients with cancer[ 30 ], may reinforce feelings of distress and anxiety and potentially promote adverse coping behaviors including increased alcohol consumption[ 3 , 31 ]. Previous surveys of US adults demonstrated increased alcohol consumption for approximately 10–40% of respondents during the pandemic[ 2 – 5 , 7 , 10 , 19 ], as well as higher scores on measures of alcohol use disorder[ 5 – 8 , 32 ]. These findings are consistent with evidence linking increased alcohol consumption and binge drinking to stressful or catastrophic events, including the September 11 th terrorist attacks[ 33 – 36 ], Hurricane Katrina[ 37 , 38 ], and the 2007–2008 financial crisis[ 39 , 40 ]. In the present study of patients with cancer, we found that only 9% of surveyed respondents increased their alcohol consumption during the Covid-19 pandemic while 23% decreased their consumption, which was higher than reported in earlier survey studies from the US[ 3 , 4 , 41 , 42 ]. It is highly likely that participants were motivated to reduce their drinking because of concerns related to cancer treatment, as nearly 54% of respondents who reported decreased drinking listed this as a primary motivation. Decreased drinking may also have been driven by closure of drinking establishments, fewer opportunities for socialization due to lockdowns, or decreased income due to the pandemic[ 43 ]. Consistent with this, decreased drinking was associated with negative financial effects of Covid-19 in our sample. We confirmed previous findings that individuals who increased their alcohol consumption during the pandemic were more likely to have experienced moderate to severe distress, or to have a previous diagnosis of anxiety or depression compared to stable drinkers[ 3 , 9 , 11 , 15 – 18 , 20 , 21 , 44 ]. Our results are consistent with previously published findings of Wisconsin residents, as Pomazal et al. reported that participants from the Survey of the Health of Wisconsin were more likely to increase their alcohol consumption during the Covid-19 pandemic if they had depression or anxiety[ 45 ]. We did not find a strong association between increased drinking and negative financial effects of the pandemic, except for respondents aged 60 or older. In our sample of patients with cancer, increased alcohol consumption was more common in younger participants (i.e. <60 years), which is consistent with other studies from the Covid-19 pandemic[ 10 , 16 , 19 , 44 , 46 , 47 ]. Increased alcohol consumption was also higher for female compared to male participants (10% vs 8%, respectively), as reported in other Covid-19 pandemic surveys of US residents showing that women were more likely to exceed recommended drinking limits[ 5 ], increase their scores on the alcohol use disorder identification test (AUDIT-C)(6), or to increase the number of days with heavy drinking[ 10 ]. Higher rates of increased alcohol consumption by female participants in our sample may have been related to higher levels of depression or anxiety and emotional distress compared to male respondents. Unexpectedly, a history of depression or anxiety and moderate to severe distress were also more common in respondents who decreased their alcohol consumption (compared to stable drinkers), suggesting that the relationship between mental health and changes in alcohol consumption during the pandemic may be influenced by other contextual or environmental factors, or that these participants employed other adverse coping mechanisms. These associations may have been influenced by the stress related to cancer diagnosis and treatment, as participants who decreased their drinking were 1) diagnosed with cancer more recently; 2) primarily motivated by concerns related to cancer; and 3) approximately twice as likely to be receiving chemotherapy, compared to stable drinkers. The finding that younger participants were more likely to change their alcohol consumption during the pandemic likely reflects a reaction to multiple compounding and major disruptions since young adults, especially female patients, often carry a greater burden of childcare responsibilities and, during the pandemic, were responsible for adapting to school closures in addition to facing cancer and cancer treatment[ 48 , 49 ]. The associations between increased alcohol consumption and mental health variables were sensitive to the choice of reference group. For participants who increased their drinking, a higher prevalence of depression or anxiety diagnosis was found relative to stable drinkers, but not compared to participants who abstained from alcohol before and during Covid-19. Likewise, the positive association between increased alcohol consumption and distress was still present but attenuated in comparison to non-drinkers. Like participants who decreased their drinking, alcohol abstainers may have been motivated by concerns related to cancer, as this group was more likely to currently receive chemotherapy compared to stable drinkers. Likewise, alcohol abstainers may have a history of addiction or a more complicated medical history characterized by conditions such as diabetes that contraindicate alcohol consumption[ 50 ]. Consequently, the associations between mental health variables and increased alcohol consumption during Covid-19 may not generalize to patients who already abstained from alcohol. Alcohol may have multiple harmful effects on tumor biology, promoting tumor growth and invasiveness, inhibiting anti-tumor immunity from the innate and adaptive immune systems, and reducing the therapeutic efficacy of chemotherapy and immunotherapy[ 12 ]. Importantly, higher alcohol consumption has been linked to poor prognosis across multiple cancer subtypes, including increased risk for recurrence, metastasis, and mortality[ 12 , 13 ]. In the present sample of patients receiving cancer care in the state of Wisconsin, participants were more than twice as likely to decrease rather than increase their drinking during the Covid-19 pandemic, and this may reflect concerns about cancer or the receipt of chemotherapy. However, patients who report anxiety or depression, or are experiencing moderate to severe distress may be susceptible to increased alcohol consumption and may therefore benefit from counselling or education designed to limit or reduce drinking. This study has several limitations. Our study included a one-time survey, and causal relationships cannot be inferred. Reverse causation is possible, as excessive alcohol consumption may contribute to depression, while alcohol withdrawal due to cutting back may have increased distress levels in participants used to self-medicating with alcohol. Due to the cross-sectional study design, we were unable to evaluate whether changes in alcohol consumption were transient or persisted throughout the pandemic. Because drinking habits prior to the Covid-19 pandemic were not assessed, we were unable to quantify the longitudinal change in alcohol consumption or identify participants who moved into a different category of alcohol consumption (e.g., from ‘light’ to ‘heavy’ drinking), or investigate whether participants with pre-existing alcohol use disorder were more likely to increase their drinking [ 6 , 46 , 51 ]. Because pre-pandemic alcohol consumption was not quantified, participants were asked to describe their change in alcohol consumption (e.g. “a little more” or “a lot more”) but clear guidelines for these terms were not provided. Further, because change in alcohol consumption was obtained via retrospective self-report, this primary outcome may be subject to inaccurate recall or intentional underreporting. Our sample was predominantly White and non-Hispanic, reflecting the demographic makeup of the catchment area for the Carbone Cancer Center, and consequently our results may not generalize to more demographically diverse populations. Further, our measures of depression and anxiety depended on self-report rather than a comprehensive clinical assessment. Conclusions In conclusion, in a survey of patients with cancer receiving care in the state of Wisconsin, increased alcohol consumption during the Covid-19 pandemic was positively associated with poor mental health, including history of anxiety and depression and moderate to severe distress. These results corroborate previous findings in healthy, non-cancer populations and highlight the relationship between stressful or traumatic experiences and potentially harmful changes in alcohol consumption. Although pandemic mitigation measures have largely been rescinded, patients with cancer remain at elevated risk for Covid-19 infection and mortality, which may have adverse effects on mental health outcomes including anxiety and distress. Medical providers should be aware that poorer mental health is consistently linked to changes in drinking patterns and should be prepared to screen patients and offer referrals to counseling as well as guidance or resources to address their alcohol consumption. Supplementary Material Supplementary materials NIHMS1968144-supplement-Supplementary_materials.pdf (201.9KB, pdf) Acknowledgements: The authors would like to thank Eileen McGuine, Claudia Vredeveld, Kaitlyn Lappen-Landwehr, Nicole Korp, and Kirstie Chu for their assistance with data collection; Oliver Eng for assistance with data linkage; Dr. Amanda Parkes for advice on study design; Jenna Igl, Stephanie Krislov, Bryan Summ, and Kyle Frisch for study support; and Julie McGregor for project coordination. Funding: This study was supported by the National Institute of Health grant UL1TR002373 to the University of Wisconsin-Madison Institute for Clinical and Translational Research and a grant from the National Cancer Institute to the University of Wisconsin Carbone Cancer Center (P30CA014520). The funding sources had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. Footnotes Competing interests: The authors have no relevant financial or non-financial interests to disclose. Ethics Approval: This study was performed in line with the principles of the Declaration of Helsinki. The Health Sciences Institutional Review Board provided approval for this study. Consent to participate: All participants provided written informed consent. Data availability: Participants did not consent to data sharing for this project, and consequently data are not available. References 1. Bantounou MA. 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[ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials Supplementary materials NIHMS1968144-supplement-Supplementary_materials.pdf (201.9KB, pdf) Data Availability Statement Participants did not consent to data sharing for this project, and consequently data are not available. ACTIONS View on publisher site PDF (531.2 KB) Cite Collections Permalink RESOURCES Similar articles Cited by other articles Links to NCBI Databases Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top

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