key: cord-1051597-u32frpau authors: Clay, J. M.; Stafford, L. D.; Parker, M. O. title: Poor inhibitory control and stress as risk-factors for alcohol (mis)use during the COVID-19 pandemic in the UK: a national cross-sectional study across four generations date: 2020-09-25 journal: nan DOI: 10.1101/2020.09.24.20197293 sha: 8dbc992715d13edd4fb7cedfa2c1c737548b074e doc_id: 1051597 cord_uid: u32frpau Background: The impact COVID-19 on the UK population's alcohol intake is unknown. We assessed change in alcohol-use and hazardous drinking during the first lockdown, and tested the hypothesis that variation would be predicted by stress and inhibitory-control. Methods: We interrogated cross-sectional data from the first sweep of the COVID-19 longitudinal survey, comprising 4 national cohorts (13 453 respondents, 19-62 years). Respondents self-reported their alcohol use, stress, and inhibitory control. We regressed change in drinking and alcohol misuse on stress and inhibitory control, adjusting for covariates to account for demographics. Findings: 29.08% 30-year-olds increased alcohol use post-COVID-19. Stress was a major contributing factor to increased alcohol use in 30-year olds (adjusted OR 3.92, 95% CI 1.17 - 13.15), as was inhibitory control in 19-year-olds (adjusted OR 1.14, 95% CI 1.05 - 1.23), 30-year-olds (adjusted OR 1.18, 95% CI 1.05 - 1.33) and 50-year-olds (adjusted OR 1.06, 95% CI 1.01 - 1.12). We identified several interactions between stress and inhibitory control in all age groups, suggesting a complex age-specific relationship between the risk factors and alcohol use and misuse during the pandemic. Interpretation: In the UK, alcohol use increased in up to 30% of the population during COVID-19, resulting from a combination of factors including poor inhibitory control and stress. It is critical in future lockdowns that clinicians and public health officials are aware of the challenges faced by different age groups, and prioritise and personalise interventions and prevention measures appropriately. Funding: ESRC, Foundation for Liver Research. lifestyle and stress that might impact on alcohol consumption among at-risk individuals during any future lockdowns. Similarly, additional support for those that may go on to develop an alcohol use disorder or relapse needs to be put in place. All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 25, 2020. . https://doi.org/10.1101/2020.09.24.20197293 doi: medRxiv preprint Since being first identified in Wuhan, China, in December 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19, has caused a significant threat to global health. 1 Governments around the world responded by imposing 'lockdowns' (orders to remain at home, and socially isolate) on their populations, and available evidence supports this action as a means of mitigating the rate of spread of the virus. 2 However, the indirect impact of lockdown on public health has raised concern, particularly relating to mental health and wellbeing. 3 In a correspondence in the May 2020 issue of The Lancet Public Health, we raised concerns that the lockdowns may increase alcohol misuse, particularly in people at high-risk of developing, or reestablishing, hazardous alcohol use. 4 An example of individuals who are at high risk of alcohol misuse are people that display poor inhibitory control (i.e., reduced ability to withhold an inappropriate response, or propensity to make 'risky' decisions without appropriate reflection or forethought). 5 Indeed, overwhelming evidence from pre-clinical (animal models), neuroimaging, and heritability studies, suggests that poor inhibitory control is both a risk factor for the development, and consequence, of substance misuse and addiction. [6] [7] [8] The association between stress and alcohol use is also well-established. 9 Similar to inhibitory control, stress plays a critical role in both the onset and maintenance of alcohol misuse and addiction. 10 On the one hand, the acute anxiolytic properties of alcohol motivate some individuals to drink. 11 On the other, perhaps counterintuitively, alcohol acts as a stressor, whereby, acute exposure stimulates the hypothalamic-pituitary-adrenocortical (HPA) axis through direct activation of the paraventricular nucleus. 12 Further, exposure to either chronic stress or chronic alcohol misuse both lead to blunted stress responses, including dysregulation of the HPA axis -a known risk factor for hazardous drinking and addiction. 13 We have recently found evidence that suggests a complex interplay between inhibitory control, stress, and alcohol use, where an experimentally-induced acute psychosocial stressor increased craving for alcohol, and subsequent alcohol consumption, in healthy (non-addicted) individuals. 14, 15 The strength of these stress-induced increases in alcohol craving and consumption were predicated on individual differences in risk-taking personality traits, stress-reactivity, and stress-recovery. Collectively, this suggests these underlying (e.g., poor inhibitory control), and environmental (e.g., stress) factors may combine to make particular individuals more at risk. Here, we analysed the first sweep of the Centre for Longitudinal Studies (CLS) COVID-19 survey -16 which was answered by individuals from five nationally representative cohorts who have been providing data since childhood -to investigate: (1) the UK's alcohol use during the pandemic; and (2) the extent to which, as predicted, poor inhibitory control and/or stress were associated with any change in alcohol use. All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 25, 2020. . https://doi.org/10.1101/2020.09.24.20197293 doi: medRxiv preprint The survey design, recruitment procedure, and fieldwork processes have been described in detail elsewhere. 17 Briefly, the CLS COVID-19 survey was administered to five nationally representative cohorts, each from a different generation, all born in the UK, who have been completing surveys about their lives and development since childhood. These included: (1) the Millennium Cohort Study (MCS), who are part of 'Generation Z', and were aged 19; (2) Next Steps, who are part of the 'Millennial' generation, who were aged 30; (3) the 1970 British Cohort Study (BCS70), who belong to 'Generation X' -aged 50; (4) the National Child Development Study (NCDS), who were aged 62 and were born in the latter part of the 'Baby Boomer' generation; and (5) the National Study of Health and Development (NSHD), who were born at the beginning of the 'Baby Boomer' era, and were aged 74. The survey was issued to 50 479 individuals across the five cohorts (including parents of the children recruited into the MCS) between 2 and 31 May 2020. Overall, 18 042 of those invited responded, achieving a response rate of 35·7%. Due to data availability at the time of analysis, four of the five cohorts included in the COVID-19 survey were analysed. Namely: the MCS cohort members (n = 2645), Next Steps (n = 1907), the BCS70 (n = 4223), and the NCDS (n = 5178). The study was restricted to UK-based respondents, thus non-UK residents (n = 500) were excluded prior to analysis. This left 13 453 cases for analysis. Selected sample characteristics are shown in Table 1 . Alcohol use behaviour was measured using five questions taken from the Alcohol Use Disorders Identification Test (AUDIT; appendix p2). 18 Several short versions of the AUDIT have been All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Stress was assessed using a single question where participants could respond: "More than before", "Same -no change", and "Less than before" (see appendix p2 for details). Inhibitory control is conceptualised as one of the core executive functions, and is a multifaceted construct consisting of several subcomponents, including motor impulsivity (i.e., action inhibition, action cancellation), sensitivity to delay (i.e., delay discounting, patience), and sensitivity to risk/reward (i.e., risk-taking, sensation seeking). 21 Here, two single ten-point Likert scales items were used to assess patience and risk-taking (appendix p2 for details). A selection of covariates, guided by the literature (see appendix p3 for details) on associations with hazardous alcohol use, were included in models, including the respondent's sex, ethnicity, National Statistics Socio-economic Class (NS-SEC) prior to the outbreak of Coronavirus, and economic activity during the pandemic. Stata IC (version 16·1) and R (version 3·6·2) were used for all analyses. The 'patience' item was reverse scored such that higher scores reflected greater impatience. AUDIT and items were re-coded to reflect their respective scoring from the literature. Scores reflecting alcohol use prior to, and during, the pandemic were calculated by summing AUDIT questions one and two (see appendix p2 for details). A change in alcohol use variable was created by subtracting alcohol use scores during the pandemic from scores prior to the outbreak. A score reflecting alcohol misuse during the outbreak was derived by summing all of the administered AUDIT questions and categorising the scores proportionally to the original AUDIT: a score 0-3 was coded as "Low risk"; a score 4-6 was classified All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 25, 2020. . https://doi.org/10.1101/2020.09.24.20197293 doi: medRxiv preprint as "Increasing risk"; scores 7-8 were labelled "Higher risk"; and scores of nine or greater were classed as "Highest risk". Inverse probability weighting was used to account for bias introduced due to missing data, and to ensure the results were as representative as possible. The overall percentage of missing data was 23·43%. The median percentage of missing data by variable was 5·29% (IQR = 8·01%) -see appendix (p5) for further details. The association between inhibitory control, stress, and alcohol use was investigated using ordinal logistic regression. We first regressed change in alcohol use and alcohol misuse during the pandemic on inhibitory control, stress, and the interaction between inhibitory control and stress. We then adjusted the model estimates by including our list of covariates in our models. We noticed that the standard error among fifty-year-olds that reported being in education during the pandemic was inflated, leading to implausible results. This was due to only two fifty-year-olds females falling into this category. These cases were omitted for all regression-based analyses. Excluding this data did not change the other model results. For brevity, model estimates for the covariates are not included in text. However, full model output is presented in the appendix (pp. 6-13). JMC is funded by an ESRC Doctoral Training Partnership grant. MOP receives funding from the Foundation for Liver Research. The funders had no role in study design, data analysis, data interpretation, writing of the report, or the decision to submit for publication. The UCL Centre for Longitudinal Studies, who administered the survey, played no role in the analysis of the data, preparation of the manuscript, or decision to submit the manuscript for publication. All authors had full access to all data in the study. All authors were responsible for the decision to submit for publication. All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 25, 2020. . https://doi.org/10.1101/2020.09.24.20197293 doi: medRxiv preprint Figure1A displays the changes in alcohol consumption as a function of age and gender. A significant proportion (~⅓) of thirty and fifty-year-olds drank more during the pandemic. There were also several sex differences, but this differed according to age group. The majority of respondents in all age groups reported drinking the same amount of alcohol, or less, during the pandemic, as they did prior to the outbreak. Figure 1B shows the proportion of respondents categorised as "low risk", "increasing risk", "high risk", or "highest risk" based on their derived alcohol misuse score. Here, risk denotes an individual's level of hazardous drinking and potential of alcohol-related harm. Overall, fifty-year-olds were the heaviest drinkers. Around one-third of all respondents fell into the 'increasing risk' category, regardless of age/gender. Across all cohorts, however, the majority of participants were categorised as low risk. As illustrated in Figure 1C , females were disproportionately affected by stress during the pandemic. The majority of males reported feeling no change in stress since the start of the pandemic regardless of age. Across all cohorts, those aged thirty had the largest proportion of individuals that reported feeling more stressed since the start of the pandemic. The age group least affected by stress was those aged sixty-two. All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 25, 2020. . https://doi.org/10.1101/2020.09.24.20197293 doi: medRxiv preprint [INSERT TABLE 2 AND TABLE 3 Among thirty-year-olds, those that reported feeling more stressed since the start of the pandemic were 3·51 (95% CI 1·07, 11·56) times more likely to be at increasing, high, or highest (versus low) risk of alcohol-related harm, based on their alcohol misuse score, compared to those that reported feeling no change in stress. This effect remained after adjusting for potential confounding factors (OR adjusted = 3·92, 95% CI = 1·17 to 13·15). For nineteen-year-old participants, greater impatience was associated with increased alcohol consumption during the pandemic. For a one unit increase in impatience, the odds of reporting increased alcohol use were 1·09 (95% CI = 1·03, 1·14) times greater than reporting no change in, or less, alcohol use. When adjusted for the effects of potential confounding factors, the effect remained (OR adjusted = 1·14, 95% CI = 1·05 to 1·23). Nineteen-year-olds that described themselves as more impatient were also more likely to fall into higher categories of risk of alcohol-related harm based on their alcohol misuse scores (OR = 1·14, 95% CI = 1·04 to 1·25). This effect remained after controlling for potential confounders (OR adjusted = 1·21, 95% CI = 1·05 to 1·41). Among those ages thirty and fifty, there was a positive association between increased risk-taking and alcohol misuse. For a one unit increase in risk-taking in those aged thirty, the odds of being categorised as having increasing, high, or highest risk of alcohol-related harm was 1·19 (95% CI = 1·07 to 1·34) times greater than falling into the low risk category. This effect remained after adjusting for potential confounds (OR adjusted = 1·18, 95% CI = 1·05 to 1·33). Among fifty-year-olds, the odds of falling into the higher categories of risk of alcohol related harm were 1·09 (95% CI = 1·03 to 1·16) times greater than falling into the lower categories. This effect remained after controlling for potential confounds (OR adjusted = 1·06, 95% CI = 1·01 to 1·12). All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 25, 2020. . https://doi.org/10.1101/2020.09.24.20197293 doi: medRxiv preprint Interactions between stress and inhibitory control were age-specific. For nineteen-year-olds that reported feeling less stressed during the pandemic (compared to the same level of stress), a one unit increase in risk-taking was associated with 1·30 (95 CI = 1·02 to 1·67) times greater odds of also falling among the higher categories of the alcohol misuse scale, indicating a greater risk of alcoholrelated harm. However, when this estimate was adjusted by adding potential confounders into the model, the effect was no longer significant (OR adjusted = 1·32, 95% CI = 0·88 to 1·99). Conversely, a one unit increase in risk-taking among fifty-year-olds who reported feeling more stressed since the outbreak was associated with 13% greater odds (OR = 1·13, 95% CI = 1·02 to 1·24) of also reporting an increase in alcohol use compared to those that reported no change in stress. However, this effect was not present after controlling for confounders (OR adjusted = 1·06, 95% CI = 0·98 to 1·15). There were several interactions between self-reported pandemic-related stress and self-reported impatience, but only in the thirty-and fifty-year-old participants. Among thirty-year-olds that reported feeling less stressed, a one unit increase in impatience was associated with 21% (OR = 1·21, 95% CI = 1·01 to 1·46) greater odds of also reporting an increase in drinking compared to those that reported no change in stress. This effect remained after controlling for potential confounding variables (OR adjusted = 1·22, 95% CI = 1.00 to 1·48). For thirty-year-olds that reported feeling more stressed, a one unit increase in impatience was associated with a 12% (OR = 0·88, 95% CI = 0·8 to 0·98) decrease in the odds of reporting an increase in alcohol use compared to those who reported no change in stress. This effect remained after controlling for potential confounds (OR adjusted = 0·88, 95% CI = 0·8, 0·98). This pattern was similar in terms of alcohol misuse: for thirty-year-olds that reported experiencing less stress, a one unit increase in impatience was associated with a 30% (OR = 1·30, 95% CI = 1·07 to 1·59) increase in the odds of falling into a higher risk category of alcohol-related harm. This effect remained after controlling for potential confounds (OR adjusted = 1·31, 95% CI = 1·09 to 1·57). Finally, among the fifty-year-olds, a one unit increase in impatience alongside reporting less stress was associated with a 17% increase in the odds of placing among a higher risk category of All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 25, 2020. . https://doi.org/10.1101/2020.09.24.20197293 doi: medRxiv preprint alcohol-related harm, but only after adjusting for the effects of potential confounding factors (OR adjusted = 1·17, 95% CI = 1·04, 1·31). This study explored alcohol use and misuse during the COVID-19 pandemic in the UK using four national birth cohorts, comprising 13 453 individuals aged between nineteen and sixty-two, carried out between 2 and 31 May 2020. Our results suggest that nearly one third of thirty-year-olds, one quarter of fifty-year-olds, one fifth of sixty-two-year-olds, and one seventh of the nineteen-year-olds, drank more during the pandemic. There were several risk factors for pandemic-related alcohol use, but that these risk factors were age-specific. In the 30-year-old group, stress was a significant risk factor, with those who were more stressed since the pandemic showing a robust increased odds of hazardous alcohol use. In addition, thirty-and fifty-year-olds who rated themselves as 'risk-takers' were more likely to engage in hazardous drinking behaviour, and nineteen-year-olds who rated themselves as impatient were at increased odds of drinking more since the pandemic and displaying more hazardous drinking behaviour. Finally, the pandemic had relatively little impact on sixty-twoyear-olds in terms of stress and alcohol use, suggesting some evidence of resilience in this age group. Our findings are the first to report a nationally representative overview of the UK's alcohol use during the height of the first wave of the COVID-19 pandemic, and the risk factors associated with increased alcohol use and misuse during this period. Previous research has suggested that the Millennial generation struggle with stress management considerably more than previous generations. 22 In the present study, thirty-year-olds had the highest proportion of individuals that reported increased stress since the start of the pandemic. This group also had the highest proportions of individuals that reported increased alcohol use, and were particularly sensitive to the effects of stress during the outbreak on their hazardous drinking. Surprisingly, despite the well-established link between substance use and stress, 9,10 a main effect of stress was not observed in any other group. Instead self-report personality factors were more important in predicting many groups' escalation of alcohol use and hazardous drinking, and in some cases, a complex interaction between stress and personality. All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 25, 2020. . https://doi.org/10.1101/2020.09.24.20197293 doi: medRxiv preprint In thirty-and fifty-year-olds, for example, risk-taking personality was associated with an increased propensity to consume more alcohol and to have higher alcohol misuse scores. This corresponds to a large volume of literature which associates poor inhibitory control with alcohol misuse. [6] [7] [8] The nineteen-year-olds generally drank less. This was unsurprising considering the recently emerging evidence of the 'devaluation of alcohol' among Generation Z. 23 However, critically, nineteen-yearold participants that rated themselves as impatient drank more during the pandemic and showed higher alcohol misuse scores. This group also rated themselves as having the highest levels of impatience in the sample. Therefore, these findings raise a concern about the potential for young adults who lack impulse control to be at particular risk of an escalation of alcohol misuse following the pandemic situation. Public health officials and health workers should be particularly vigilant over the coming months (and following any subsequent national or local lockdowns) for increased alcohol use -especially among individuals with poor impulse control. It may be prudent to include measures of inhibitory control during routine assessments of alcohol use in in primary care settings, during hospital admissions, or through third sector interventions (e.g., online self-assessment tools). 24 It is clear from previous research that there is an interaction between stress and personality factors that influence drinking. For example, people who experience acute stress show increases in craving for, and consumption of, alcohol. 14,15 Here, counter-intuitively, we found that thirty-year-old participants who rated themselves as impatient, and who experienced less stress during the pandemic, drank more alcohol. Similarly, those that rated themselves impatient and experienced high levels of stress reported lower alcohol consumption during the pandemic. In addition, both thirty-and fifty-year old respondents who reported experiencing less stress during the pandemic, scored higher on the alcohol misuse scale. Collectively, these data support the hypothesis that people with lower response inhibition may have been drinking more to 'cope' during the pandemic, thus lowering their stress levels. 'drinking to cope' was a reported feature of drinking habits in the USA during lockdown, and may therefore be the case here. 25 Individuals with poor response inhibition use alcohol as a method of dealing with stress or boredom, 26 and long-term alcohol use leads to dysregulation of the HPA axis, All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 25, 2020. . https://doi.org/10.1101/2020.09.24.20197293 doi: medRxiv preprint leading to increased stress-sensitivity. 13 This is of particular concern clinically, as drinking to cope with adverse situations is predictive of an escalation of alcohol use and misuse, and may explain why poor response inhibition is so strongly related to addiction. We acknowledge several limitations in our study that must be considered. First, the survey was designed to capture information across several domains other than those relevant here. 17 Therefore, to mitigate known issues related to respondent burden (e.g., satisficing), brevity was prioritised which meant less detail in some of the measures used. For instance, single-item measures were used to assess risk-taking, impatience, and stress which may suffer from reduced content validity -thus, potentially increasing the risk for type II errors through inflated standard errors. Some of this potential error is offset by our large sample size; however, we found some effects that were not statistically significant despite moderate effect sizes (e.g., among thirty-year-olds that reported increased stress, OR adjusted = 2·18, 95% CI = 0·97 to 4·89). Further, there may be individual differences in the phenomenology of stress. For instance, some people may perceive boredom as not being stressful compared to a pre-pandemic life. Therefore, this may explain why some that reported poor inhibitory control and lower levels of stress also reported increased alcohol use. Second, there is no way to independently verify self-report drinking, and it is well-known that people under-estimate the alcohol consumption when asked on questionnaires due to social desirability bias, and often a lack of detailed memory of drinking episodes. It may, therefore, be that our data under-represents the true extent of drinking during the pandemic. In summary, this study demonstrates that the COVID-19 pandemic has been associated with an increase in alcohol consumption in the UK, with approximately 14% to 30% of individuals reporting increased alcohol consumption depending on age and sex. Of these, a substantial number of individuals (between approximately 4% and 10%) reported dangerously high levels of drinkingagain, this varied by age and sex. Stress was a risk-factor among thirty-year-olds, with those reporting more stress being 3.92 times more likely to engage in hazardous drinking. We also found evidence that young adults (nineteen-year-olds) that reported lower inhibitory control were around 14% more All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 25, 2020. . https://doi.org/10.1101/2020.09.24.20197293 doi: medRxiv preprint likely to drink more during lockdown, and were approximately 21% more likely to engage in hazardous drinking. Similarly, for thirty-year-olds those that reported lower inhibitory control were 18% more likely engage in hazardous drinking. Our findings provide the first national data on the impact of COVID-19 lockdown measures on alcohol misuse, complementing other work that has shown that patients with existing alcohol use disorder were at risk of relapse during the pandemic. 26 It is critical that, in future lockdowns, governments carefully consider the impact of change of lifestyle and stress that might impact on alcohol consumption in at-risk individuals. The UK government may, for example, consider age-specific strategies, 27 or limiting alcohol sales, the latter of which has been the case in other countries. 28 On behalf of all authors, the corresponding author states that there is no conflict of interest. The authors state that the views expressed in the submitted article are their own and not an official position of the University of Portsmouth. JMC and MOP conceived the study and carried out initial literature searches. JMC completed the analysis and created the figures. All authors contributed equally to interpretation of the results and critical revisions of the manuscript. JMC and MOP wrote the first draft of the manuscript. LDS provided critical comments during the drafting process. LDS and MOP contributed to study supervision. All authors read and approved the final version of the manuscript. All data used in this study are available from the UK Data Service Website (https://ukdataservice.ac.uk/) under the "Safeguarded" data access policy. The primary dataset used is referenced under study number 8658. Ethnicity data associated with the MCS, Next Steps, BCS70, and NCDS cohorts are referenced under study numbers 6073, 5545, 5558, and 5565 respectively. All analysis code is available on the Open Science Framework website (https://osf.io/wf2rj/). All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 25, 2020. All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 25, 2020. . https://doi.org/10.1101/2020.09.24.20197293 doi: medRxiv preprint All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 25, 2020. . https://doi.org/10.1101/2020.09.24.20197293 doi: medRxiv preprint World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19) How will country-based mitigation measures influence the course of the COVID-19 epidemic? Mental health and the Covid-19 pandemic Alcohol use and misuse during the COVID-19 pandemic: a potential public health crisis? A Systematic Meta-Review of Impulsivity and Compulsivity in Addictive Behaviors Genetic influences on impulsivity, risk taking, stress responsivity and vulnerability to drug abuse and addiction Addictions NeuroImaging Assessment (ANIA): Towards an integrative framework for alcohol use disorder Genetic overlap between impulsivity and alcohol dependence: A large-scale national twin study The role of stress in drug addiction. An integrative review Alcohol use in the UK during the COVID-19 pandemic Note: NS··SEC = National Statistics Socio··economic class prior to the outbreak· Economic activity reflects activity during the pandemic· 95% confidence intervals associated with proportions were calculated using the Agresti-Coull method.