With most states legalizing medical cannabis, and others legalizing recreational cannabis use, or decriminalizing cannabis possession, there has been a great deal of interest into how this may affect alcohol use and outcomes. The common debate amongst those for and against the legalization, with regard to alcohol, are the ideas of cannabis as a substitute (those for) or as a complement (those against). Why does it matter? Well, if cannabis and alcohol are substitutes, meaning increases in cannabis use result in decreases in alcohol use, there could be a reduction in alcohol related costs such as healthcare, traffic accidents, dependence, and even deaths [3]. Consuming alcohol can lead to organ failure and other health issues, which can not be said for cannabis. If the two substances are complements, legalization would result in an increase use of both cannabis and alcohol, increasing the costs referenced above significantly. Consuming both simultaneously could lead to even more individual and societal harm than what alcohol causes alone.

Multiple studies have been done trying to understand cannabis legalization’s effects on alcohol in the states which have already legalized it, but it is a hard issue to navigate and truly understand because much of the available research is politically motivated, whether it be influenced by conservative values, liberal values, or the alcohol industries deep pockets; and if I learned one thing from my bio-statistics class, it is that data can be easily manipulated to give the results you want. Also, there has been limited research done on how it could affect women and men differently. The only way we can truly understand the relationship between cannabis and alcohol consumption is if more unbiased research is done, looking at specific indicators and populations.

So, what has the available research shown us so far?

Arguments and evidence for substitution:

Decrease in Alcohol Sales and Consumption:

Our very own Georgia State University professor, Alberto Chong, published a 10-year study that showed alcohol sales dropped 13% in states with medical marijuana laws [2]. While a separate study showed a decrease in the per-capita sales of beer [3]. Alcohol consumption and likelihood of becoming a frequent drinking has also dropped in states with legal medical and/or recreational cannabis, especially amongst high-schoolers and young adults [3]. A reduction in sales and consumption is considered direct evidence of cannabis as a substitute for alcohol.

Decrease in Alcohol Related Harms:

If cannabis use increases and alcohol use decreases, we would expect to see a large reduction in alcohol related harm. There are no fatal effects of overusing cannabis, unlike binge drinking alcohol, which can kill you quickly and unexpectedly. College students are known to partake in binge drinking, with consequences including alcohol poisoning, drunk driving, and assault. One study showed that alcohol binge use dropped 6% in states with legal recreational cannabis, with an even larger drop in students over 21 years old [1].  Multiple studies on medical, recreational, and decriminalization found a reduction in fatal alcohol related traffic accidents, and emergency room visits mentioning alcohol [1,3]. Though there is little evidence on cannabis’ addictiveness, we know alcohol is highly addictive, so increased cannabis use could reduce the lifelong struggle and health and treatment costs of alcoholism.

As a substitute coping mechanism:

Though using any substance to cope is not good for one’s mental health, using cannabis instead of alcohol could be a better alternative because of the above-mentioned harms associated with alcohol. Substitution depends on a similarity between substance effects. “Neuroscience research indicates that marijuana and low-dose alcohol use share neuro-pharmacologic effects of reward and sedation,” giving evidence to similar effects [3].  

College students who tended to use drugs/alcohol to cope showed a substitution effect switching to cannabis, with women less likely to co-use cannabis with alcohol [8]. Dr. Chong and his fellow authors also found evidence of an increase in women using cannabis to self-medicate instead of turning to alcohol [2]. In Washington state legalization of recreational cannabis led to a large decrease in alcohol related harms at home and financial harms for women [7].

Amongst 350 adult customers of medical marijuana dispensaries in Berkeley California, researchers found that 40% of them reported using cannabis as a substitute for alcohol due to its less severe symptoms, better symptom management, and less withdrawal potential [3].

Arguments and evidence for complementary:

Cannabis use and Co-use harms:

Further relaxing controls on cannabis use could lead to more developmental effects on young adults underdeveloped brains, especially since there is a connection between cannabis and increased risk for psychosis [1]. Also, since cannabis is most commonly used through smoke inhalation, there could be significant lung issues from chronic use. Multiple studies against legalization use the “gateway drug argument,” with one study showing cannabis use is associated with later symptoms of alcohol disorders [3]. Women’s progression to cannabis use disorders (CUD) is much faster than males and despite women using cannabis less regularly than men, they have more severe psychiatric, medical, and employment complications. [6] Also adolescent girls are more likely to meet the criteria for cannabis abuse [6].

When alcohol and cannabis are used simultaneously there is more risk and danger than when either is used alone, “for example, those who use marijuana and alcohol together have the highest rates of unsafe driving” [3]. Studies have also shown that THC (tetrahydrocannabinol) levels increase if alcohol is consumed simultaneously resulting in more pleasurable mood effects [3]. This might lead to people combining the substances to reach a better high. If judgment or decision-making is impaired by cannabis, unintended increases in alcohol consumption could result.  

Academic performance:

College students who use cannabis infrequently by itself have lower GPAs, and those who report co-use have an even greater decrease in their GPAs, affecting males more than females [5]. This is mostly likely due to cannabis impairing mental functioning and memory. Students were also less like to graduate on time or even be enrolled their senior year [8]. Those who were less likely to use drugs normally, showed a complementary effect in states with legal recreational cannabis, reporting co-use approximately once a month [8].

So, what does all this mean?

Alcohol and cannabis have both been used since the earliest recorded human history and have been the two most commonly used intoxicants in the United States for decades. The early stigma of cannabis use in the United States is a result of racism and prejudice, propaganda portraying users (minorities) as thieves, rapists, and murders, with no scientific evidence backing these claims up [4]. The increasing amount of evidence on the health benefits of cannabis has begun to break down the negative connotations associated with its use. If the stigmas are broken down even more, that could lead to better unbiased research. Also, with limited evidence for both positive and negative effects of cannabis use for women, future research should focus on better determining the difference between sexes.

With alcohol laws changing at the same time as cannabis laws, it can be hard to show correlations between the two. Whether showing a substitution or complementary effect, most studies made sure to mention that substance use, no matter which substance, most importantly depends on prices, age, availability, convenience, and what motivates one to drink [3,8]. To better understand the public health implications and inform policy decisions, the factors that influence substance use must be identified. And no matter whether they are substitutes or complements, moderation is still critical. Its important to mention that cannabis legalization and use could have no effect on alcohol issues. So, what does all this mean? We’ll have to wait and see.

References:

1. Alley, Z. M., Kerr, D. C., & Bae, H. (2020). Trends in college students’ alcohol, nicotine, prescription opioid and other drug use after recreational marijuana legalization: 2008–2018. Addictive Behaviors, 102, 106212. doi: 10.1016/j.addbeh.2019.106212
2. Baggio, M., Chong, A., & Kwon, S. (2017). Helping Settle the Marijuana and Alcohol Debate: Evidence from Scanner Data. SSRN Electronic Journal. doi: 10.2139/ssrn.3063288
3. Guttmannova, K., Lee, C. M., Kilmer, J. R., Fleming, C. B., Rhew, I. C., Kosterman, R., & Larimer, M. E. (2015). Impacts of Changing Marijuana Policies on Alcohol Use in the United States. Alcoholism: Clinical and Experimental Research, 40(1), 33–46. doi: 10.1111/acer.12942
4. Ivanov, K. (2017, March). High Times: The evolution of the stigma on marijuana and attempts to tear it down. Retrieved from https://www.lakeforest.edu/live/news/8003-high-times-the-evolution-of-the-stigma-on
5. Meda, S. A., Gueorguieva, R. V., Pittman, B., Rosen, R. R., Aslanzadeh, F., Tennen, H., … Pearlson, G. D. (2017). Longitudinal influence of alcohol and marijuana use on academic performance in college students. Plos One, 12(3). doi: 10.1371/journal.pone.0172213
6. Secades-Villa, R., & Fernández-Artamendi, S. (2017). Gender Differences in Cannabis Use Disorders. Handbook of Cannabis and Related Pathologies, 131–137. doi: 10.1016/b978-0-12-800756-3.00015-6
7. Subbaraman, M. S., & Kerr, W. C. (2020). Subgroup trends in alcohol and cannabis co-use and related harms during the rollout of recreational cannabis legalization in Washington state. International Journal of Drug Policy, 75, 102508. doi: 10.1016/j.drugpo.2019.07.003
8. Suerken, C. K., Reboussin, B. A., Egan, K. L., Sutfin, E. L., Wagoner, K. G., Spangler, J., & Wolfson, M. (2016). Marijuana use trajectories and academic outcomes among college students. Drug and Alcohol Dependence, 162, 137–145. doi: 10.1016/j.drugalcdep.2016.02.041
9. Tardosky, E., Tardosky, E., Tardosky, E., Meyer, M., Meyer, M., Meyer, M., … Meyer, M. (2020, January 11). Cannabis vs Alcohol in 2020: Drinking Deaths on the Rise, is Marijuana the Answer? Retrieved from https://www.healthmj.com/cannabis/alcohol-marijuana-use/

               Its well known that alcohol has a correlation with intimate partner violence (IPV) with many studies over the years showing this relationship. Alcohol is an aggravator of IPV because of its dis-inhibitory effect on aggression, suppression of a person’s ability to negotiate and navigate volatile situations, while increasing lack of self-control. The United Nations Population Fund recent estimates suggest that at least 15 million cases of IPV will occur due to COVID-19 lock-down measures; and with alcohol sales increasing drastically across the globe during lock-down, there’s bound to be a connection between the two. For relationships already suffering domestic abuse during the pandemic, alcohol adds fuel to the fire, but with all the other stressful factors caused by COVID-19, new cases of violence and abuse could emerge. Alcohol and IPV not only have a relationship with the perpetrator and violence incidents, but also with the victim and their increased likelihood of alcohol abuse.

Alcohol consumption by the abuser during lock-down:

                Since we already know alcohol can aggravate domestic violence, when combined with the isolation, stress, economic anxiety, and unemployment caused by the pandemic and shelter in place orders, perpetrators are more likely to turn to abusive behaviors, taking out stress and anger on their partners. Not only does the rate of abuse increase with alcohol consumption, but also the severity of abuse. With bars and restaurants closed due to lock-down measures, abusers must drink at home, while victims are unable to leave and get away from them, increasing the risk of IPV.

A core component of IPV is the perpetrator controlling and isolating their victim, which the pandemic has created perfect conditions for. Women trapped at home may be unable to call for help due to their abusers’ constant surveillance of their daily actions and phone and/or social media.

Another worrisome fact is that gun sales are also increasing. This fact, combined with increased alcohol consumption, makes the risk of domestic violence related homicide a growing concern. There are already reports across the globe of intimate partner homicides related to factors due to the pandemic.

IPV and lock-down increasing women’s alcohol abuse:

For women in abusive relationship who have alcohol disorders, the pandemic may be worsening their dependence or likelihood of relapse.  Victims of IPV are twice as likely to consume alcohol than their partner who perpetrated the abuse according to a study published by the Institute of alcohol studies. This could be due to how women use alcohol as a means of self-medicating to numb the pain of abuse. Increased IPV and other anxieties already heightened by the pandemic lead to more victim’s turning to alcohol to cope. For recovering addicts such stressors could lead to their relapse during lock-down.

Furthermore, institutions where victims tend to seek emotional support and moments of freedom from their abusers are now closed, taking away healthy coping mechanisms that reduce alcohol use. It is a Catch-22 situation: COVID-19 stressors increase alcohol consumption by the perpetrator, this alcohol consumption increases violence against their partner, this violence increases emotional stress, and thus alcohol consumption by the victim. A difficult cycle to stop.

For women with alcohol dependencies, an abuser may use alcohol as a method of control, maintaining and enabling the addiction. Financial hardships increase this control if a woman is unable to seek help on her own because of economic or job loss.

Has banning alcohol during lock-down helped?

                Though most countries that have banned alcohol sales during lock down did so for social distancing purposes, a few others implemented bans for the sole purpose of curbing domestic violence. It’s difficult to tell whether such measures have helped due to the many factors associated with IPV, but multiple reports have shown continued increases in IPV during the pandemic even with alcohol bans.  One example being India, where there was a four-fold increase in domestic violence calls from women after their husbands lost their jobs. While with the alcohol ban, there was no significant difference in the number of women seeking treatment due to IPV at hospitals. One program director exclaimed, “There is no difference in their [husbands] treatment of women really. They would abuse the women when they had alcohol, and now they are abusing them because they don’t.” This sentiment portrays the idea that the root causes of IPV need to be address, rather than just blaming alcohol.

Repercussions that could continue after the pandemic:

                The increase in alcohol consumption and IPV during COVID-19 could lead to many consequences that continue on even after the pandemic ends. Unintended pregnancies due to sexual violence could prevent a woman from leaving an abusive relationship. The consequences of alcohol abuse increase among IPV victims could persist as well. If a woman does try to leave the relationship after lock-down ends, it could result in her death since most intimate partner homicides happen when the women tries to leave. With so many unknowns on how exactly the pandemic will negatively impact outcomes of IPV, communities need to be prepared with initiatives to support these women during these times as well as afterward.

National Domestic Violence Hotline: 

References:

Campbell, A. M. (2020). An increasing risk of family violence during the Covid-19 pandemic: Strengthening community collaborations to save lives. Forensic Science International: Reports, 2, 100089. doi: 10.1016/j.fsir.2020.100089

Centre for Public Health. (2006). Intimate partner violence and alcohol [Fact sheet]. World Health Organization. https://www.who.int/violence_injury_prevention/violence/world_report/factsheets/fs_ intimate.pdf

Domestic Abuse and Women’s Alcohol Issues. (2020, April 15). Retrieved from https://www.alcohol.org/women/domestic-abuse-and-alcoholism/

Flair, L. N. L., Bradshaw, C. P., Storr, C. L., Green, K. M., Alvanzo, A. A. H., & Crum, R. M. (2012). Intimate Partner Violence and Patterns of Alcohol Abuse and Dependence Criteria Among Women: A Latent Class Analysis. Journal of Studies on Alcohol and Drugs, 73(3), 351–360. doi: 10.15288/jsad.2012.73.351

Institute of Alcohol Studies. (2014). Alcohol, Domestic Abuse and Sexual Assault. London.

Srivastava, R., & Harrisberg, K. (2020, May 5). Will lockdown alcohol bans affect domestic violence? Retrieved from https://news.trust.org/item/20200505191710-1niva

Stanley, M. (2020, May 9). Why the Increase in Domestic Violence During COVID-19? Retrieved from https://www.psychologytoday.com/us/blog/making-sense-chaos/202005/why-the-increase-in-domestic-violence-during-covid-19