Exploring factors related to alcohol and substance use during the COVID-19 pandemic: a post-hoc analysis from the Korea youth risk behavior web-based survey

1. Introduction

Alcohol and substance use in adolescents is harmful, and excessive use is a global concern.[1] The Global Burden of Disease (GBD) study found that one-third of adolescents have used alcohol in their lifetime, and approximately 14% of the total health burden can be attributed to drug abuse.[2, 3] Furthermore, alcohol and substance use in adolescents is a major contributor to global increases in morbidity and mortality.[4] Thus, preventing substance use in youth is an important public health priority.[5] Rapid changes in socioeconomic factors, public policy, technology, and mental health have influenced alcohol and substance use patterns over time.[6-8] We have previously conducted an analysis on this matter and, through further in-depth analysis, have proceeded with additional research.

2. In-depth analysis

A total of 1,109,776 adolescents were included in the KYRBS-related current alcohol use analysis from 2005 to 2021 (Fig. 1 and 2).[9]

Fig. 1. Trends of adjusted OR of alcohol use between 2005 to 2019.

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Fig. 2. Trends of adjusted OR of substance use between 2005 to 2019.

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Among one million adolescents during the pandemic (2019 versus 2021), lower school grades (ratio of odds ratio [ROR], 1.172; 95% CI, 1.075-1.279), male (ROR, 1.098; 95% CI, 1.008-1.197), lower educational levels of parents (ROR, 1.116; 95% CI, 1.002-1.215), and lower economic levels (ROR, 1.341; 95% CI, 1.026-1.754) were more pronounced and significant among alcohol users compared to the pre-pandemic period (Table 1 and 2). In addition, similar patterns were observed in-depth analysis (2005-2019 versus 2020-2021; Fig. 3).

Fig. 3. Odds ratios for association between associated factors and alcohol use by time period divided by COVID-19 pandemic happening. Odds ratio was calculated for one unit increase in BMI (1kg/m²). Horizontal lines indicate corresponding 95% confidence intervals around odds ratios. BMI, body mass index.

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During the pandemic (2019 versus 2021), higher school grades (ROR, 1.561; 95% CI, 1.166-2.090) and former smoking (ROR, 1.969; 95% CI, 1.290-3.003) were more pronounced and significant among substance users than in the pre-pandemic period (Table 3 and 4). In addition, similar patterns were observed in-depth analysis (2005-2019 versus 2020-2021; Fig. 4).

Fig. 4. Odds ratios for association between risk factors and substance use by time period divided by COVID-19 pandemic happening. Odds ratio was calculated for one unit increase in BMI (1kg/m²). Horizontal lines indicate corresponding 95% confidence intervals around odds ratios. BMI, body mass index.

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3. Comparison with previous studies

Most previous systematic reviews conducted worldwide on drug usage focused only on the mental, psychological, or social consequences of substance abuse, 23 while some focused only on risk factors for the non-medical use of prescription drugs, except for social conditions among youths.[10]

Recent systemic reviews on the risk factors of adolescents’ substance or alcohol use found that the majority of the studies (13 articles) were from the United States of America (USA), three studies were from Asia, four studies were from Europe, and one study was from Latin America, Africa, and the Mediterranean.[11, 12] The number of sample participants varied widely between studies, ranging from 70 participants (minimum) to 700,178 participants (maximum), while one qualitative study utilized 100 interviewees.[11] However, their small sample size, short-term follow-up period (mostly less than six years), and inappropriate study design (non-representative or non-random selection of participants, including convenience, purposive, or volunteer sampling) have potentially contributed to low levels of evidence and inconsistent results.[11, 12] Furthermore, most studies have been conducted in America or Europe.[11, 12] These studies have only shown the risk factors for substance or alcohol use up to the pre-pandemic period.[11, 12] However, our study provides adolescents’ risk factors for alcohol or substance use and the odds ratio to easily compare the change between the pre-pandemic and during pandemic periods. Furthermore, body mass index (BMI), depression, and lower economic status were strongly related to alcohol and substance use during the COVID-19 pandemic. The COVID-19 pandemic may lead to increased social isolation, depression, anxiety,[3, 13] low levels of physical activity, unhealthy diets, and subsequent weight gain, as well as increased consumption of alcohol and substances.[14, 15] Moreover, the COVID-19 pandemic has considerably impacted on household income due to premature deaths, workplace absenteeism, and reduced productivity, leading to unemployment.[16, 17] It may result in economic problems, depression, and a subsequent increase in alcohol and substance consumption.[18, 19]

4. Policy implication

Many unhealthy habits start in adolescence, and when alcohol and substance use begins at an early age, there is a high likelihood of developing substance use in future life.[20] Alcohol and substance addiction significantly impact people, families, and communities and can lead to issues and negative impacts on social, physical, and mental health.[21] As a result, it is important to identify high-risk adolescents and provide them with preventative services, daily monitoring of youth health data, and prevention programs, for example, the PROSPER device,[22] the “4-H Health Rocks” device,[23] and the unplugged program. As the COVID-19 pandemic has changed the trend of young people’s alcohol and drug use in particular,[24] it is crucial to identify various factors associated with alcohol and substance use to develop policies that will lessen young people’s use of them.[20]

In this study, adolescents who were depressed, had low socioeconomic status and had higher BMI, were more vulnerable to alcohol and drug use during the COVID-19 pandemic. Considering these findings, it is psychiatric counseling is recommended, such as education for lowering anxiety and depression levels, promoting home-based physical activities, and aiding cognitive behavioral therapy based in school and community settings.[25] Relatively higher risk of alcohol and substance use during the pandemic in economically vulnerable adolescents might also have been affected by increased health-related stress, less peer support, and vulnerability to health-related stress in this population.[26] Special attention to decreasing these gaps between adolescents from lower-income and higher-income families is necessary for the late stages of the COVID-19 pandemic.[27]

5. Strengths and limitations

This post-hoc study examined large population-based data from a nationwide investigation of factors associated with adolescent alcohol and substance use in Korea. Long-term data from 2005 to 2021 were used, making it easier to track changes in the variables related to alcohol and other substance use.[28] The changes during the early and mid-pandemic periods were confirmed by including data from 2021.

This study had several limitations. First, data from a self-report questionnaire were used to gauge adolescent substance and alcohol use. Owing to social desirability bias, this may understate the true prevalence of adolescents’ substance use. However, a previous study suggested that this questionnaire is generally reliable in determining estimates (kappas ≥0.81).[29] Second, a detailed analysis of each type was constrained by the unknown specific types of substances used. This could result in a bias in the adolescent substance use trend toward the specific substance they used. Third, the findings may not reflect the global population because our data only included South Korean adolescents.[30] International large-scale studies investigating the factors associated with substance and alcohol use in youth are warranted to clarify this issue. Fourth, to reduce the number of questions in the in-depth smoking survey, the amount of substance usage, which did not significantly affect the results, was excluded from the 2015 survey. However, since 2016, substance use has been included in an annual survey without a circular survey. Therefore, the 2015 substance usage survey data were omitted from the KYRBS, which could have skewed the conclusions of this study. Finally, because the late period of the COVID-19 pandemic was not included in this study, it must be continuously reviewed to account for additional risk factors during the late stage of the pandemic.

The study protocol was endorsed by Kyung Hee University (KHUH 2022-06-042) and the KDCA, who provided written informed consent.

6. Conclusion

Over a million adolescents’ national data were used in this study to investigate changes in alcohol and drug use according to risk factors from 2005 to 2021. Moreover, we compared how they were affected by the COVID-19 pandemic by comparing the change in risk factors in the pre-pandemic (2005–2019) and pandemic periods (2020–2021). The outcomes of this study suggest a complex interaction between a multitude of factors that influence adolescent alcohol and substance use. Among these variables, school grades, male, lower educational levels of parents, and smoking status were more pronounced and significant in adolescents with alcohol and substance use. This may be due to the COVID-19 pandemic. Therefore, after the pandemic, for successful prevention of alcohol and substance use in adolescents, greater control of risk factors is needed.