Extended lockdown and India's alcohol policy: a qualitative analysis of newspaper articles.

OBJECTIVES: Since 25th March 2020 India went into a complete and extended lockdown. Alcohol production, sales, and purchase were barred with this overnight prohibition order. We conducted a qualitative analysis of the media reports published within the first month of the nationwide lockdown with the objectives (a) using the media reports as indications of possible public health impact and population response of a sudden alcohol prohibition in India, (b) suggesting areas for future research.
METHODS: We performed thematic and content analysis of 350 articles published online in national newspapers between the 26th March, 2020 and 25th April, 2020. Initial inductive, followed by deductive coding was done in this exploratory thematic analysis.
RESULTS: The thematic analysis revealed four main themes: the beneficial aspects of the policy, the harmful aspects of the policy, non-compliance and attempts to change and / or subvert the policy, popularity and level of public buy-in of the policy. We generated relevant sub-themes under main themes. Two additional themes, not directly related to the sudden prohibition, were use of stigmatizing language and ethical concerns. The content analysis showed the frequency of the appearance of the main themes and proportions of sub-themes and codes under those main themes.
CONCLUSION: The harms, perceived from the media reports, should be balanced against the potential benefits. Absence of a national-level alcohol policy was made apparent by the reflexive, disconnected , and conflictual measures. Future research could systematically examine the potential ramifications of alcohol prohibition on public health, social, and economic aspects.

Introduction

According to the nation-wide survey published last year, an estimated 160 million (14.6 percent) people in India consume alcohol and 29 million (2.7 percent) were dependent on it (Ambekar ). In addition to the number of people who are dependent on alcohol an additional 29 million (5 percent) experience hazardous consumption. More than 60% of alcohol consumed consisted of “spirits” (i.e. Indian made foreign liquor and country-made liquor) (Ambekar ; Benegal, 2005; Gaunekar ; Mohan, Chopra, Ray, & Sethi, 2001). Among the SEAR countries, India had the highest yearly per capita alcohol consumption of 5.7 litres (World Health Organization, 2018). All these three factors together pose a serious public health threat. The proportion of young drinkers rose from 2% to 14% in the last two decades, and the age of initiation declined from 19 years to 13 years (Prasad, 2009). The threat is multiplied by an added concern of a powerful alcohol lobby, led by multinational corporations, which targets India's emerging market of young drinkers (Schess, Jambhale, Bhatia, Velleman, & Nadkarni, 2018). The enthusiasm of the corporations is fuelled by a steady change in the level of acceptance and attitude towards alcohol from a culture of abstinence to ambivalence to covertly permissive (Benegal, 2005; Prasad, 2009). India needed a national level alcohol policy to minimize the public health impact of the aforementioned factors. However, India's alcohol policy is governed by the states. The three main pillars of the policy are- supply reduction to prohibition; taxation; and tertiary prevention (Schess ). Presently, alcohol sales and consumption is illegal in five of the 36 states and union territories of the country, whereas for a large majority of other states alcohol sales-tax constitutes 15–20% of their total revenues (Benegal, 2005). The Government of India does not receive any taxation revenue from alcohol. Taxation, although used successfully elsewhere, has not been effective in India to reduce consumption because of easy access to unrecorded alcohol (e.g. illicit or tax evaded). As per the Global Status Report (2018) nearly half of the total alcohol consumed in the country fell in the unrecorded category (World Health Organization, 2018). Preventive services such as community-based, school or college-based prevention programs, brief intervention at primary care, and emergency services are mostly non-existent in India.

To this backdrop of a population vulnerable to serious public health impact, ineffectual policy, and a motivated third-party, since 25th March 2020 with overnight notice, India went into a complete and extended lockdown, with the intention to contain the spread of SARS-CoV-2. Alcohol being a non-essential commodity, all production, sales, and purchase were prohibited akin to an overnight prohibition order, enforced by the Government of India. There was, however, an inherent contradiction to the enforcement of a national level policy because alcohol policy was a state-subject until that point. In normal times, the constitutional scheme ensures the autonomy of the states with regard to the spheres of activities earmarked for the states in the Constitution. However, exceptions can be made during emergencies (Arora, 2009). The main arguments behind the Government of India's prohibition were: alcohol's potential harmful effect on the immune system, possible flouting of physical distancing and hand hygiene under the influence of alcohol, the possibility that alcohol may contribute to the domestic violence which was on the rise during the pandemic, and finally to reduce the healthcare burden resulting from alcohol-related accidents and violence (Nadkarni, 2020). We read several newspaper reports of suicide, consumption of illicit and harmful liquor or non-alcoholic beverages within a week of the lockdown. A research report from a tertiary care hospital in southern India showed a significant increase in the number of patients with complicated alcohol withdrawal (Narasimha ; Pulla, 2020). India was not the only country to impose a nation-wide prohibition during the COVID-19 pandemic. South Africa, Sri Lanka, Thailand, and Greenland, have also forced similar restrictions (French, 2020). Results of prohibition from South Africa portrayed a beneficial effect. An article from the Washington Post quoted the director of alcohol research at the South African Medical Research Council, reporting 5000 fewer admissions to the trauma units following the week of prohibition. The modelling of data by the council showed at least 15 people are being saved every single day, who would have otherwise died from alcohol-related traumas (Mogotsi and Bearak, 2020; Council, 2020). Sri Lankan media, on the other hand, reported the proliferation of home-breweries and illicit distilleries across the country, and the availability of high-price alcohol in the grey market (Rakshit, 2020). Hence, prohibition seems to have different effects across countries. There were still other countries such as Canada, the US and the UK which designated alcohol as an essential commodity and continued the supply during the pandemic. Several commentators have discussed the harmful effects of such policies- encouraging the general population to drink and sending a message that alcohol is essential for lives (Hobin & Smith, 2020; Neufeld, Lachenmeier, Ferreira-Borges & Rehm, 2020).

A direct population survey, which would have been ideal to understand the effect of prohibition, was not possible under the present circumstances. Therefore, alternative data sources can be explored. Researchers so far have used alcohol sales data or isolated media reports (Nadkarni, Kapoor & Pathare, 2020; Borges & Rehm, 2020). We wanted to systematically explore the scope of the media reports, using the media as an indicator of potential harms and benefits. At the same time we acknowledge that media as a data source can be biased, and there are issues with accurate factual reporting and reliability. Therefore, the result of this paper should be read with these caveats in mind.

We conducted a qualitative analysis of the media reports published within the first month of the nationwide lockdown with the objectives of (a) using the media reports as indications of possible public health impact and population response to a sudden alcohol prohibition in India, (b) suggesting areas for future research.

Methods

Study design

The study had an exploratory design which systematically looked at the response of individuals, public and society at large, government and non-government organizations which primarily deal with public health and related aspects of alcohol by studying newspaper reports.

Data sources and search strategy

By a consensus among the authors, the following search words were selected. Type of news-items was only in English, published between 26th March to 25th April with the search words: "Alcohol", "Alcohol policy", "state", "Alcohol treatment", "illicit liquor", "Alcohol ban", "Alcohol revenue", "Alcohol suicide", "Alcohol lobby", "Alcohol e-marketing", "Alcohol withdrawal", "Alcoholics", "Chief minister Alcohol", "Isopropyl alcohol", "Alcohol revenue" "Alcohol poisoning", "alcohol price" "Alcohol home-delivery". The search was made on Google News (India).

The rationale for using Google News India was as follows: a large majority of the best selling newspapers in India have a digital version (e-paper). Hence, an online search on Google news India, in addition to the exclusively online media reports, was likely to uncover the reports of the online editions of the print media. Besides, there were two other reasons for screening the media reports through Google News- (a) the COVID-19 pandemic resulted in nearly 80 percent decline in the print newspaper sales in different cities India (GoNews Desk, 2020), (b) India has a growing number of internet users and it is second largest in the world. More than 98 percent of internet users use Google as their search engine (Mishra & Chanchani, 2020), (c) the lockdown, travel restrictions, and closure of libraries, and outlets selling newspapers had made it impossible to check the print editions.

The choice of only English papers was determined given that (a) the eighth schedule of the Indian Constitution recognized 22 languages and English was (and still is) one of the official languages across Indian states. Therefore, a search of English media reports was likely to be more generalizable than searching in different regional languages; and (b) most widely circulated English newspapers (e.g. Times of India, Hindustan Times, The Indian Express) have versions in Hindi and other regional languages.

The period includes the most intensive phase of lockdown between 25th March and 14th April when there was a virtual clampdown on all activities and people were not allowed to step out of their homes. Only emergency and essential activities like purchasing essential food, attending hospital, and attending pharmacies were allowed during this period. After 15th April there was some relaxation in some of the states but mostly all states were in lockdown with heavy restrictions on non-essential activities.

Analysis and Interpretation

Qualitative thematic analysis was done by the coding, categorization and theme generation which was done after meticulous data immersion. A comprehensive coding frame with definitions and examples for each item was designed by peer debriefing and researcher triangulation to guide the coder in identifying the main four themes and sub-themes.

The codes were generated inductively under the broad domains of 'impact of alcohol prohibition policy among various stakeholders’ and 'response to the prohibition policy' for the newspaper reports of the initial two weeks that is till 5th April. For the remaining 2 weeks a deductive approach was taken for coding. However, any additional codes, discovered were documented and discussed. Two of the authors (AG and AB) independently undertook the coding. AG and AB are both qualified addiction psychiatrists and have been working in the field of addiction medicine for more than six years.  All the coding was done manually. Each characteristic was coded as being either present (1) or absent (0). We did not force concordance between the investigators in order to explore multiple perspectives. In case of any additional code generation by one of them (AB or AG), it was taken into account by mutual consensus.

Once all the codes were finalized, themes and sub-themes were generated by triangulation. A diagramming approach was taken to understand the connections between the themes and subthemes. The themes were labelled tentatively with the objective of finalizing the names following the third team meeting.

Three team meetings and peer debriefings were done during this period. The first meeting aimed to (a) document theoretical and reflexive thoughts; (b) share thoughts about potential codes. The second meeting was held following the inductive code generation and creation of the coding framework. The third meeting was held with the objectives of (a) ratifying any additional codes; (b) discussing the main themes and sub-themes and vetting by the team members. The overarching flow of ideas was noted. In sum we assumed a factist epistemological paradigm, the emerging categories/sub-themes and themes led us to an overall understanding of the response of all the stakeholders to this sudden prohibition

The themes, sub-themes, and codes retrieved from each article were entered into an excel sheet by TM and these were cross-checked by AG. The frequencies were mentioned in the content analysis

We followed the methodology by Göbekli and Nowell .

Ethical clearance was obtained from the All India Institute of Medical Sciences, Rishikesh, India- ethics committee (Ref: 54/02/PSY/2020–167).

Results

A total of 350 news articles from 90 newspapers were accessed for the study. For further details please see the article selection flow diagram (Fig. 1 ).

Fig. 1

Flow diagram of article search and selection.

……The three major newspapers contributing to these media reports were: Times of India (11.1%), The Hindu (6.6%), and The Indian Express (5.7%). For other mastheads please see supplementary table 1. All articles were published between 26th of March, 2020 and 25th of April, 2020. Among them, 157 articles had only online publication and the rest (193) had both print and online versions. The news articles from national and regional news were 86 (24.5%) and 264 (75.5%), respectively.  Regional articles were from 22 states and union territories.  Kerala (20.8%), Karnataka (9.7%), Telangana (8%), Tamilnadu (7.4%), and West Bengal (5.7%) were the first five states represented in the regional news. The types of articles and their states of origin are depicted in supplementary table 2. Fig. 1 gives a detailed distribution of the states represented in the analysis.

………Four main themes emerged when all the 350 articles were analysed: (a) “the beneficial aspects of the policy,” (b) “the harmful aspects of the policy,” (c) “non-compliance and attempts to change and/ or subvert the policy,” and (d) “popularity and level of public buy-in of the policy.” We could identify two additional themes, which could not be considered as direct repercussions of the sudden prohibition, nevertheless were important markers of societal attitudes towards individuals who use alcohol. These themes are "use of stigmatising language" and "ethical concerns".   Table 1 gives an example of the coding schemes, and generation of sub-themes and themes.

Table 1

A Prototype of Themes and Sub-Themes With Their Associated Codes.

Article excerpts	Codes	Sub-themes	Themes
“..a directive by the Chief Minister of Punjab declared the supply of beverages as essential items, along with groceries in light of the urgency due to COVID-19 pandemic..” (Srivastava, 2020)	Inclusion of alcohol in the list of essential commodities	Non compliance of the states	Non-Compliance And Attempts To Change And/ Or Subvert The Policy
“The Assam government … has given permission for the opening of liquor shops for a limited time in the state… According to the order by the Additional Commissioner of Excise, the Indian Made Foreign Liquor (IMFL) shops shall open from 10:00 AM to 5:00 PM on the permitted days.” (FPJ Webdesk Correspondent 2020, Letter sent by Shri SK Medhi April 12, 2020)	Limited hours sale of alcohol
“According to a government order issued to the excise commissioner, Director General of Police, Managing Director of the Kerala State Beverages Corporation and the health department, the Beverage Corporation authorities must issue limited quantities of Indian Made Foreign Liquor (IMFL) to those who are in possession of the 'passes'…”(Jayakumar, 2020)	Distribution of special liquor passes
“The Chief Minister has said the government is also considering the option of online sale of liquor as the sudden unavailability of alcohol may lead to social problems.”(SNS, 2020)“…the Kerala State Beverages Corporation, which is the sole distributor of liquor in the state, decided to deliver liquor at doorsteps of the needy”(Raghunath, 2020)	Plans for online delivery and doorstep delivery
“In an apparent bid to shore up revenues, the West Bengal government has decided to impose 30 per cent sales tax on wine and beer, sources in the finance department said on Monday. The government issued a notification in this regard on April 7 and the new prices came into effect from April 9”(PTI, 2020)	Tax hikes
“..an Excise officer said most of the prescriptions did not have the seal of the doctors and were fake. Some brought prescriptions from retired and private doctor..”(Express News Service, 2020)	Forging prescriptions for obtaining alcohol passes	Non compliance at the individual level
“A COVID volunteer was arrested by the Varkala police on Saturday for selling alcohol made using various components, including sanitisers, and for selling it to clients to whom he delivered it on his bike.”(Express News Service, 2020)	Attempts to brew alcohol at home
“Amid the nation-wide lockdown, a Hyderabad resident distributed alcohol pegs among the people……Yesterday I was returning to my residence in Hyderabad‘s old city after completing my work, meanwhile in Champapet area I noticed that a woman suffering from convulsion/fits due to alcohol. She was shifted to a hospital later on. Other people are also there who desperately need alcohol, as they are addicted to it. I had an alcohol bottle at my residence. So, I thought of distributing alcohol pegs to such people…”(News18, 2020)	Good Samaritan response
“...there have been several instances of alcohol thefts that have been reported across states. For instance, in Maharashtra, four incidents of thefts were reported within a span of 48 hours from liquor shops and beer bars which are shut from March 18 after the government ordered the lockdown. The thieves ran away with liquor worth over Rs 1 lakh from all the four places”	Thefts/Robberies of bars, liquor shops and hotels	Illicit and criminal activities
“With liquor vends shut since the nationwide lockdown, authorities in Delhi have cracked down on those selling or transporting alcohol illegally…In April, 855 bottles of IMFL, 12,503 bottles of CML and 4868 bottles of beer were seized by the police. Police also intercepted an ambulance, which was illegally transporting 25 cartons of liquor.”(PTI, 2020)	Smuggling illicit liquor and spurious liquor
“Several residents of DLF Phase 1, South City, Sohna Road and Golf Course Road fell into the trap of “liquor home delivery” and lost nearly ₹4000 in each case, the police said.”(Dhankar, 2020)	Online scams

Fig. 2 depicts the themes and sub-themes in a nutshell.

Fig. 2

State-wise distribution of main themes, sub-themes, and codes.

The themes, sub-themes, and codes.

The beneficial aspects of the policy

The main theme “beneficial aspects of the policy” is represented by the following codes:

Opportunity for treatment

Several medical practitioners described the lockdown as “an opportunity for treatment” of persons with alcohol dependence. As per a newspaper report, a document generated by the National Drug Dependence Treatment Centre, All India Institute of Medical Sciences (AIIMS), referred to the lockdown situation as a blessing in disguise for some people who could use this opportunity to quit drinking altogether (Phull, 2020).

Increase in treatment-seeking

Media reports indicated that the number of people presenting with alcohol withdrawal to functioning outpatient services and emergency departments of general and psychiatric hospitals, and addiction treatment centres showed a sharp rise in the weeks following the enforcement of the lockdown. The articles reflected similar news coming largely from the southern parts of the country (Kerala, Telangana, Tamilnadu) both from the cities and the rural districts.

One news report quoted the superintendent of the Institute of Mental Health in Erragadda, Hyderabad saying -

"We have received 96 to 100 patients today who are suffering from withdrawal symptoms. Close to 90 per cent of them are dealing with the withdrawal of alcohol.." (Mojumder, 2020)

Reports from addiction treatment centres under the department of excise in Kerala, “Vimukthi”, read- “According to the officials of Vimukthi, ever since then, in just a week's time, 64 people were admitted to the 14 deaddiction centres under Vimukthi alone. “This is not the usual pattern. Not more than 20–30 people usually get admitted to the Vimukthi centres in a week….” (Mithun & Joseph, 2020)

Calls to the national helpline numbers as well as different state helplines for alcohol and other substance use saw an unprecedented rise. A title of one news article read -

“Coronavirus lockdown: Helpline for drug addicts, alcoholics reports 200% surge in calls”(Businesstoday.in, 2020a)

A hospital from Tamilnadu, too, reported within the first week of the ban - “We have been getting at least five to six calls per day from places like Chennai and Hyderabad in the past week, and the number is sure to go up as the lockdown progresses” (Nainar N, 2020)

Involvement of the self-help groups

Alcoholics Anonymous (AA) arranged for telephonic communication as part of a pan India initiative to continue their meetings during the time of lockdown severely restricting movement. With the use of conference calls and different slots for better coordination, these meetings are being held. The reports were from both southern and north-eastern states namely from Kerala, Karnataka, and Meghalaya.

Reports read- “In a pan India Initiative, AA is using telephonic communication where callers are put on a conference call – since people are working from home, different slots are provided. Regional meetings are also held separately. The addicts’ families can participate in the conference calls. Only addicts will be allowed to speak,” said a member of Karnataka area committee, AA…..” (De'sousa, 2020)

Tele-consultation services

Telemedicine and tele-counselling services were initiated in different parts across the country. In one of the states, a free online counselling platform was launched. In several places, counsellors worked from home, attending calls from patients or their family members (Mithun & Joseph, 2020).

Reduction of domestic violence

One of the opinion types of article indicated a possible beneficial aspect of the alcohol prohibition could be a reduction in domestic violence (Agarwal & Srivas, 2020). Their assumption was based on a study conducted in the slums of Mumbai, which revealed women whose husbands consumed alcohol were two times more likely to experience intimate partner violence than those whose husbands did not consume alcohol (Begum, Donta, Nair & Prakasam, 2015). This report assumed significance in the background of increased complaints of domestic violence received by the National Commission for Women, within the first one week of lockdown (Khandekar, 2020).

The Harmful Aspects Of The Policy

As a recent study estimated, an approximate 57 million people in India had problematic use of alcohol, almost half of whom consumed alcohol in a dependent pattern (Ambekar ). The newspaper reports possibly indicated the distress experienced by this population, reflected by the following codes.

Suicide

This was perhaps the most tragic and extreme fallout of the sudden unavailability of alcohol and one of the first news topics related to the ban on alcohol which came to light. The southern state of Kerala reported the death of 6 people by suicide within the first 3 days of lockdown (Jayakumar, 2020). As per the news reports, all such deaths could be attributed to severe distress from marked withdrawal symptoms in these persons with alcohol dependence. In addition to Kerala, suicide deaths or attempts allegedly due to non-availability of alcohol were reported from Assam, Meghalaya, Karnataka, Chattisgarh, Telangana, and Tamil Nadu. Although the media predominantly observed these deaths by suicide as a fall-out of distress due to non-availability of alcohol some did report alternative or additional perspectives of mental health problems and depression (Swamy, 2020).

Consumption of non-consumable alcohol

According to the media reports, as people resorted to desperate measures to access alcohol, some people drank non-consumable forms of alcohol such as paint varnish, after-shave lotions or hand sanitisers. Within the first couple of weeks of lockdown, several such incidents were reported from Tamil Nadu where 6 people died after drinking hand sanitisers or paint varnish and soft drinks mixed with after-shave lotion (DHNS, 2020). One such case was also reported from Kerala, and nine from Uttar Pradesh (Swamy, 2020).

Consumption of illicit and spurious liquor

Media reported that sales of illicit liquor shot up rapidly following the ban. Although the prices were several times higher than usual, stocks of illegally bought liquor were clearing at a very rapid pace. Few people could afford such high prices. Those not having enough money, looked for cheaper alternatives and often ended up consuming spurious liquor, risking their health. Reports of illicit and spurious liquor consumption and resultant deaths and hospitalizations were reported from Uttar Pradesh and Tamil Nadu (Siddiqui, 2020).

Alcohol withdrawal in migrant adolescents

In the slums of Hyderabad, one newspaper report noted that this significant population of teenage children of poor migrant workers with alcohol dependence, began to experience symptoms of marked alcohol withdrawal. The article quoted the head of a non-profit organisation running shelter camps in the city saying -

“At least 20 minors in the camps sheltering over a hundred migrant workers and homeless persons have been showing moderate to severe withdrawal symptoms.”(Menon, 2020)

Closure of private de-addiction centres

The high demand for treatment was not always met with a corresponding increase in the treatment provisions. Media reports suggested that most of the private de-addiction centres decided to remain closed or function only with the admitted patients, due to the lockdown. All new patients were referred to government hospitals for management. Due to most centres refusing new admissions and referring patients to government hospitals, people seeking treatment remained unattended. However, such reports came only from Tamil Nadu (Lakshmanan, 2020).

Non-Compliance And Attempts To Change And Or Subvert The Policy

We could identify the following three sub-themes under this main theme- non-compliance at the state level, at the individual level, and illicit or criminal activities.

Non-compliance from the States

Inclusion of alcohol in the list of essential commodities

The states of Kerala and Punjab had initially included alcohol among the list of essential commodities, to continue its sale even post lockdown. In Kerala, while private liquor stores were closed, the state-run Kerala State Beverages (Manufacturing and Marketing) Corporation Limited (BEVCO) remained open. However, both states had to stop following directives from the government of India. The government of Punjab had requested government of Indiato allow the sale to address the significant loss of revenue which followed banning the sale of alcohol. In tune with this, the International Spirits and Wine Association of India, lobbied the Government of India to classify alcohol as an ‘essential item’.

Limited hours sale of alcohol

The northeastern states of Assam and Meghalaya allowed the sale of alcohol for limited hours on permitted days while under strict enforcement of social distancing and other precautionary measures (ANI Correspondent, 2020). In Assam, the state government allowed the opening of liquor shops, from 10 am to 5 pm. Distilleries, breweries, bottling plants were also allowed to open (Additional Commissioner of Excise, 2020). In Meghalaya, liquor stores opened from 9 am to 4 pm from 13th to 17th April. Only a single member from each household would be permitted to buy, along with measures restricting movements between the districts. Meghalaya also permitted home delivery of alcohol in areas without liquor shops. However, following a second directive from the Government of India refusing any relaxation to alcohol sale or production, both states had to withdraw their orders.

As per Times of India 7th April report, The Excise department of Govt of Karnataka made a proposal to allow sale of liquor between 10 am and 1 pm. The newspaper reported that this may improve excise earning and state revenue but on the flip side of it sale for only a few hours a day may lead to huge rush thereby violating guidelines to prevent the virus (Gejji, 2020). However, later it was withdrawn by the Karnataka Government.

Distribution of special liquor passes

In Kerala, the state government formulated plans to supply alcohol upon certification by a government medical practitioner that the person was experiencing symptoms of alcohol withdrawal. The government cited the recent suicides among those experiencing alcohol withdrawal as the primary reason for initiating this unprecedented step. It decided to issue special "liquor passes" from the state excise department on the production of such certification (Government of Kerala, 2020) They placed a limit of 3 litres of alcohol per person for a week and plans were to supply the alcohol to the homes of the applicants (PTI, 2020a).

Plans for online delivery and doorstep delivery

The state of West Bengal had started making plans to enable online home delivery of alcohol, ensuring that the norms of social distancing were maintained while attempting to generate revenue from the sales. The state of West Bengal saw a discrepancy between the messages conveyed by police and excise departments regarding the same piece of information, again suggesting inter-department incoordination (FPJ Webdesk, 2020a). Kerala had planned doorstep delivery so that crowding at liquor outlets could be avoided. However, none of the plans could be enacted. In those areas without liquor shops, Meghalaya has allowed home delivery (Team Latestly, 2020). There have been various whatsapp groups forwarding numbers of people selling alcohol in metro cities like Mumbai at escalated rates (FPJ Webdesk, 2020b).

Tax Hikes

As mentioned in the Press Trust of India and corroborated from the notice issued by the revenue department of the Government of West Bengal, the state government attempted to make up for the loss in revenues by imposing a sales tax of 30% of the MRP in addition to the existing excise and additional taxes (PTI, 2020b; Government of West Bengal, 2020) However, for alcohol users who were forced to pay up to 100 % more than the usual price as per different newspaper reports (TNN, 2020).

Non-compliance at the individual level

Forging prescriptions for obtaining alcohol passes

When the government of Kerala decided to provide special "liquor passes" through the state excise department, to persons experiencing signs and symptoms of alcohol withdrawal upon certification by a government medical practitioner, a large number of fake prescriptions were detected. Most lacked the doctor’s seal while some were from retired doctors, private doctors or Ayurvedic practitioners all of which led to the rejection of their applications. A newspaper report read, “an Excise officer said most of the prescriptions did not have the seal of the doctors and were fake. Some brought prescriptions from retired and private doctors (Express News Service, 2020a).”

Attempts to brew alcohol at home

Another way that people responded to the situation was trying to brew alcohol at home. An article read, “Some social media users are also trying to brew and share recipes for home-made alcohol (De sousa, 2020).” Another newspaper reported an incident of selling illicit home-made liquor by a “socially connected” person from Kerala, “A COVID volunteer was arrested by the Varkala police on Saturday for selling alcohol made using various components, including sanitisers, and for selling it to clients to whom he delivered it on his bike (Express News Service, 2020b).” People were also using free rice given in ration shops for the preparation of country liquor - this has been reported from Assam (G Plus News, 2020). In some parts of West Bengal previously banned liquors were again found to be brewed. An example:

‘Rakshi, a traditional distilled Nepali beverage banned in Bengal, has suddenly outstripped illicit country liquor in demand in several parts of Barrackpore police commissionerate during the lockdown. Police have found out that a few Nepali families, who sell momos and other Chinese fast food, at Khardah are behind the revival of the strong drink that is usually made from rice, barley or millet’(Chaudhury, 2020)

Good Samaritan response

A newspaper article reported on one of the most circulated viral videos showing a man distributing alcohol to daily wage workers in Hyderabad, prompting varying comments of "crazy", "fame-seeking", "dev-maanush (Godsent)” and also sparked debates on the pros and cons of the ban (Khandekar, 2020).

Illicit or criminal activities

This one month period saw a spate of illegal activities related to the consumption of alcohol. While some struggled to cope with the sudden stoppage of alcohol, others saw opportunities to make money through illegal means, often leading to disruption and arrests. The following codes illustrate such activities.

Thefts/Robberies of bars, liquor shops and hotels

Amidst the unavailability of alcohol, there have also been a growing number of thefts and robberies of bars and liquor stores. The majority of such reports came in from the states of Karnataka, Maharashtra, Tamil Nadu, Telangana, Chhattisgarh and Andhra Pradesh along with capital Delhi (Shekhar, 2020).

Smuggling illicit liquor and spurious liquor

While the sale of alcohol from legal outlets remained closed, there was an increase in smuggling illicit and spurious liquor. There were frequent reports of seizures of large amounts of illicit liquor by the authorities. Innovative means of smuggling were seen such as hiding alcohol in milk cans or sale from authorised milk booths, while reports came in of a stash of 25 cartons of liquor in an ambulance in Delhi (PTI, 2020c). Grey market sellers during this time charged double the price and even hooch was expensive (Reuters, 2020). Alcohol was sold under the garb of essential items and medications - it was found to be smuggled in milk cans by a person posing as a milkman or as homeopathic medications (Joshi, 2020; Team Newsable, 2020).

Online Scams

As people continued to search for alcohol, several reports of online scams came to the fore. Most of these gangs established contacts through social media, promising online delivery of alcohol, usually charging exorbitant rates, meanwhile getting access to bank account details and often making away with large sums amounting to lakhs of rupees. While authorities cautioned against such fraudulent activities, people’s desperate search for alcohol often led them to these traps. News of such frauds were reported in different parts of the country with the cities of Kolkata, Mumbai, Bengaluru, Hyderabad, Gurugram, Mangalore witnessing many such cases. Social media has also been used as a tool by online fraudsters claiming to sell alcohol and people selling illicit liquor or home-brewed liquor to access their target population, with anonymity inherent in this medium of communication undoubtedly promoting such use. As an example, several residents have been cheated online by making payment through e-wallet or other UPI platforms, as reported by the media outlet, Hindustan Times (Dhankhar, 2020).

Newspapers have also reported details about the modus operandi of such illegal transactions of alcohol, such as:

The masterminds “would never meet the buyer anticipating that he would get caught. He would cross- check the name of buyers on True Caller before processing the deal,” said an official. After stashing the liquor bottle at the designated spot, he would call the buyer and give the location. He would hide and watch from a distance to ensure that the liquor reached the right person’ (The Hindu Correspondent, 2020b).

Popularity And Level Of Public Buy-In Of The Policy

The prohibition of alcohol enforced by the Government of India received a mixed response from the stakeholders, as detailed in the media analysed herein. While a large number of states, organizations of alcohol manufacturers and sellers, and a few celebrities opposed the ban, a few other states, health professionals, and the judiciary supported or upheld the prohibition (PTI, 2020d).

Views of the alcohol sellers and manufacturers

The different sellers’ bodies repeatedly tried to draw the focus towards the loss of revenue and rise in black market sales of alcohol while trying to persuade the Government of India and state governments to relax the ban on alcohol.

One newspaper report quoted the International Spirits and Wines Association of India (ISWAI) chairman saying -

"States are strapped for cash. 15 - 30 percent of a state’s revenue comes from alcohol. This is a significant revenue stream that comes directly to state coffers and can help in these cash-strapped times particularly when there is pressure to provide a safety net"( ).

Recommendations of sellers and manufacturers to the governments

The sellers' body - Confederation of Indian Alcoholic Beverage Companies (CIABC) made recommendations to the commerce minister of the Government of India, health minister and chief ministers of all states to allow home delivery of alcoholic beverages. They also focussed on the sudden lack of employment of the workers in the huge alcohol industry while urging the government to resume the sale of liquor.

Plans for phased re-openings

The CIABC and International Spirits and Wines Association of India (ISWAI) requested phased re-openings of liquor stores outside the hotspot areas, for a longer duration to reduce crowding. They also suggested providing licenses to the shops for 3–4 home delivery workers through which the government could control the frequency and the amount of liquor being delivered.

Online delivery

The sellers’ bodies also advocated for online alcohol delivery or e-tailing of alcohol. They had recommended this to minimise the gathering in front of liquor shops. They also suggested identity proof for age verification during applications made online or through phone calls.

Views of healthcare professionals

There were widely varying reactions of the medical fraternity and other sources of help to the different situations which arose in the country in relation to the ban on alcohol. The following two codes provide an illustration.

Protesting against “liquor passes”

As discussed, when Kerala decided to issue special “liquor passes” to those suffering from alcohol withdrawal upon such certification by government medical practitioners, the medical professionals in the state as well as across the country criticised the move, calling it “unethical”.  The Kerala Government Medical Officers Association (KGMOA) protested by observing a black day and wearing black badges and bands to work. News reports quoted a KGMOA office-bearer saying -

“There are scientific methods of treating people with withdrawal symptoms and that's the medical protocol. This is something which will affect our morale and numerous side effects will surface. We will not be doing this.”( )

Other medical bodies such as the IMA (Indian Medical Association) and Indian Society of Gastroenterology's Kerala Chapter refused to prescribe it, saying it was against medical ethics. The KGMOA and the IMA then filed petitions in the Kerala High Court to stop the government from proceeding further with provision of “liquor passes.”

Views against the policy

However, not all medical professionals were aligned to the policy of prohibition. The Director of the Centre for Mental Health  Law and  Policy in  Pune expressed his belief that the current alcohol crisis was a result of the states' contradictory approach to alcohol which was both puritanical and pragmatic (Hamid & Harigovind, 2020). A psychiatrist in Karnataka also filed a Public Interest Litigation against the sudden ban and advocated for allowing the liquor shops to open. This plea was turned down by Karnataka High Court (The Hindu Correspondent, 2020a).

Decision of the judiciary

The high courts of Kerala and Karnataka were primarily involved in this scenario for differing reasons. In Kerala, as mentioned above, the KGMOA and IMA filed petitions to stop the government’s decision to provide alcohol, based on certifications by doctors. The Kerala High Court stayed the move for three weeks (Prathapan TN vs State of Kerala and others, 2020). A newspaper report quoted the bench as saying -

“We are concerned that the state government has taken a unilateral decision to administer more alcohol to persons suffering from alcohol withdrawal syndrome. This is a recipe for disaster.”(Swamy, 2020)

In Karnataka, following a PIL filed by a private psychiatrist requesting reopening of liquor shops, the Karnataka high court ordered the psychiatrist to contribute Rs 10,000 to the Prime Minister’s Fund.

Loss of revenue and resultant impact on popularity of prohibition policy

The loss of revenue was cited as one of the major reasons for the states to oppose the alcohol prohibition. The estimated daily revenue loss due to stoppage of alcohol sales was around USD 9.3 million daily in India, and most of the states earned around 15–30% of their revenue from alcohol. The worst-hit states were Maharashtra, Uttar Pradesh, Telangana and Karnataka, which earned approximately USD 320 million, USD 340 million, USD 290 million and USD 267 million respectively during the financial year 2019–20.

Views reported from the Social media

We did not conduct a qualitative analysis of the social media but the thematic analysis of the newspaper reports identified a particular sub-theme with the response from the social media. In an age of digitisation and ubiquitous social networking through the internet, social media has quickly become the source of information of dubious authenticity, often acting as a tool for rumour-mongering. It has also evolved as a platform for expression of opinions of a significant portion of the population. Consequently, in the present scenario, social media platforms have been used in diverse ways.

The social media platform Twitter saw trends of #LiquorFreeIndia doing the rounds which drew a lot of reactions, both light-hearted and those with serious overtones (Saxena, 2020). A viral video depicted a political leader of the ruling party in the newly enforced prohibitionist state of Bihar, in an inebriated state and led to significant public shaming and political mudslinging.

Views from celebrities

Celebrities from different fields had their own take on the situation. While some advocated for the ban, there were others including a famous movie director who urged the state governments to relax the ban and allow alcohol sales for limited hours. Newspaper article mentioned veteran Bollywood actor's tweet: “Think. Government should for some time in the evening open all licensed liquor stores. Don't get me wrong. Man will be at home only what with all this depression, uncertainty around. Cops, doctors, civilians etc... need some release (Bangalore Mirror Bureau, 2020).

The following themes were not directly related to the alcohol prohibition but were relevant for understanding the socio-cultural milieu and newspaper reporting standards.

Use Of Stigmatising Language

A common theme that featured in most of the news articles that were analysed was the use of stigmatizing language in the context of alcohol use and dependence. Terms such as "tipplers", "addicts", "boozers" and "drunkards" used to refer to persons with alcohol dependence is a reflection of this stigma. Many of these words were used in the title of the news article (Indulekha, 2020; Nidheesh, 2020).

Ethical concerns

One of the other noticeable themes that emerged from the news reports was the lack of privacy of the affected individuals, with articles on reported suicide or isopropanol (methanol) poisoning providing detailed personal identification data.

Content analysis

We performed a content analysis to determine the frequency of the themes, sub-themes and codes. There was coexistence of different themes, sub-themes and codes within a single article. The most prevalent theme was 'non-compliance and attempts to change and or subvert the policy' which was found around 370 times in the articles. There were various state-driven endeavours to subvert this ban- like ‘distribution of liquor pass’ (n=82, 22.1%), ‘plans for online and doorstep delivery’ (n=71, 19.2%), ‘limited hours sale of alcohol’ (n=39, 10.5%), ‘Inclusion of alcohol in the list of essential commodities’ (n=12, 3.2%) and ‘tax hikes’ (n=5, 1.4%). Non-compliance at the individual level consisted of ‘attempts to brew alcohol at home’ (n=16, 4.3%), ‘forging prescription to obtain liquor pass’ (n=3, 0.8%) and ‘Good Samaritan response’ (n=3, 0.8%). There were various reports of illegal activities non-complying with this ban, like ‘smuggling of illicit and spurious liquor’ (n= 113, 30.5%), ‘Online Scams’ (n=17, 4.6%) and ‘Thefts/Robberies of bars, liquor shops and hotels’ (n=9, 2.4%).

The ‘popularity and level of public buy-in’ was the next most common theme, which appeared 181 times in our search. The main sub-themes were ‘view of healthcare professionals’ which was found 63 times in our search. ’Doctors' protest against the “liquor pass” ’(n=58, 32%). Some doctors also expressed their views against the national policy (n=5, 2.8%) As a result the judiciary had passed decisions (n=42, 23.2%). Another subtheme was ‘Views of the alcohol sellers and manufacturers’ that appeared 38 times. The alcohol sellers recommended for the resumption of business to the governments (n=38, 21%) through phased reopening of the liquor shops or online delivery. The most frequent cause proposed for these recommendations was revenue loss’ (n=17, 9.4%). There was considerable ‘social media response’ both for and against the ban (n=15, 8.3%). Celebrities (n=6, 3.3%) also expressed their opinions regarding the ban.

There were 143 accounts of the ‘harmful effects’ of the abrupt alcohol ban. It included several reports of suicide (n=82, 57.3%), fatal or near-fatal consequences of consumption of non-consumable alcohol like aftershave lotion or hand sanitizer (n=39, 27.3%), and consumption of spurious liquor (n=18, 12.6%). The other aspects of the harm were the ‘closure of private de-addiction centres’ (n=3, 2.1%) and alcohol withdrawal in migrant adolescents (n=1, 0.7%).

Although many news reports focussed on the negative and subversive aspects of the ban, there were 72 accounts of the beneficial effects of the ban. On the part of the patients, this led to increased treatment-seeking (n=37, 51.4%) for alcohol use. The service providers were also viewing this ban as an ‘Opportunity for treatment’ of patients with alcohol use disorder (n=18, 25%). As in-person consultation was not a viable treatment option, the teleconsultation services flourished as an alternative treatment platform (n=13, 18.1%), and self-help groups like ‘Alcoholics Anonymous’ also played their role in helping those in need of treatment (n=2, 2.8%). The ban on alcohol has presumably led to a relative reduction in domestic violence during the lockdown period (n=2, 2.8%).

We found the use of stigmatizing languages (like ‘drunkard’, ‘tippler’, ‘alcoholic’) in 86 articles and contents with ethical concern (like exposing the names and other personal details of suicide victims) in 16 articles.

The distribution of frequency of the themes, sub-themes, and codes are presented in Fig. 4 .

Fig. 4

Bar chart showing frequencies of appearance of themes, subthemes, and codes.

Discussion

We conducted thematic analyses of 350 articles, published over a span of one month in a wide-range of English dailies and online-only newspapers. We followed a predetermined and systematic approach to retrieve the newspaper articles, to do the thematic analysis and extraction of themes and sub-themes. We believe this was a relatively novel, feasible, resource-friendly and time-saving strategy to indicate the possible effects of this sudden national policy. . One basic premise of the rigour of this study has been the trustworthiness and reflexivity as reflected by the authors by clarifying their own perspective as addiction psychiatry professionals (Lincoln, Guba, & Pilotta, 1985). Credibility has been established by peer scrutiny of the coding process and data triangulation by a discussion of the results amongst the authors. We also carried out a content analysis of the themes to quantify the relative dominance of the themes and to make the qualitative research transparent and replicable. Both thematic and content analysis added to the methodological triangulation and the overall robustness of the qualitative study. However, the authors acknowledge that the dynamic nature of qualitative results is variable based upon the epistemological and ontological paradigms assumed (Silverman, 2005).

Drawing a causal inference (as was done by the media reports) would have been an oversimplification for several reasons- (a) the Covid-19 pandemic itself might increase the risk of suicide by enhancing the risk of mental illness, loss of employment, financial hardships, and bereavement (Gunnel ), (b) Some media reports had actually suggested a possibility of underlying depression in many of these individuals (Swamy, 2020). A psychological autopsy could have been a scientifically valid way to discern the possible causes.

Countries such as the USA, where alcohol sale was not banned during the pandemic, had witnessed several cases of methanol poisoning due to consumption of alcohol-based hand rubs (Yip et al, 2020). Similar cases, on a large scale, were also reported from Iran, which is otherwise a dry country (Haghdoost, 2020).These instances were likely to be driven by the myth that consumption of alcohol-hand rubs will kill the SARS-CoV2. Therefore, the events of consumption of non-alcoholic beverages, reported by the Indian newspapers could also be a result of similar myths.

The content analysis revealed media reports focussed more on the harmful aspects of the policy than the potential benefits of prohibition. Nevertheless, this result was not an evidence of harms outweighing the benefits because media reports were not done with scientific rigor and there was financial, political, and ideological bias inherent to the reporting.

In sum, the qualitative analysis of newspaper reports indicated potential public health-related benefits and harms of the sudden alcohol prohibition in India. Future research could systematically explore issues flagged by the media reports.

Our study results showed a few limitations in India's alcohol policy:

Firstly, alcohol policy in India was a state-matter. Therefore, ban imposed by the Government of India on alcohol unmasked the incoordination between the Government of India and the states, between the states, and even within departments of a state. The disconcerted attempts to subvert the national level policy resulted in confusion among the public and medical professionals. The judiciary had to intervene in one particular case. All these were reflective of the incoordination in the planning and implementation of alcohol policy.

Secondly, alcohol is a huge revenue generating commodity for the states and therefore, the alcohol policy is largely driven by financial incentives rather than a focus towards public health (Benegal, 2005).

Thirdly, states’ attempt to subvert the policy by the Government of India by alcohol home delivery and online delivery was potentially harmful for several reasons- (a) Evidence from Russia showed 90 percent stockpiled alcohol at home and only a very small proportion intended to use it as hand sanitizer (Neufeld, 2020). Commentators also raised the possibility of overcompensated drinking-at home in the absence of social inhibitions (Neufeld, 2020); (b) the boredom, stress, and social isolation during the pandemic could contribute to increase in alcohol use (The Lancet Gastroenterology Hepatology 2020; Hoblin & Smith, 2020); (c) economically disadvantaged group of individuals with alcohol use disorders would not be able to afford either online or home delivery of alcohol. Importantly, they are more vulnerable to alcohol-related harms as opposed to the group, which could afford such services (Katikireddi ); (d) easier access to alcohol might give a wrong message to the non-using population that alcohol is an essential commodity and reduce the public perception of harm (Hoblin & Smith, 2020). All these factors together suggested that home or online delivery of alcohol was likely to produce more harm than benefit.

The implication for the future alcohol policy

Firstly, the lockdown, prohibition, and consequent response from the stakeholders indicated a need for national alcohol policy in India. The disconnected attempts of states to restore ‘normalcy,’ discrepancies between state departments, conflicts with the Government of India, and the resultant confusion among the public could have been averted by national-level policy. Secondly, the Indian alcohol policy requires a public health reorientation, i.e. policy aimed at reducing the harms of alcohol, both at the individual and the societal level (Babor ). Beginning with the abrupt prohibition and to recurrent themes of the compulsion for the states to compensate for the excise-related revenue loss, the involvement of commercial entities in decision making (even remotely), an under-equipped health care infrastructure, and desperate measures of state to “prescribe alcohol” to alleviate suffering were some glaring examples of a lack of public-health oriented decision making. A comparison of alcohol control policies among 30 countries, across the globe, showed an inverse relationship between alcohol harms and the strength of policy measures(Brand, Saisana, Rynn, Pennoni, & Lowenfels, 2007). The strength was defined by the “Alcohol Policy Index,” with public health as the basic common denominator. Thirdly, the “suddenness” of the prohibition might have been responsible for most of the potential harms and confusion between the states and the Government of India . A discussion with the states and other stakeholders prior to the enforcement of the prohibition could have resulted in a more coordinated implementation of the policy. Fourthly, the harmful aspects of the prohibition were largely applicable to individuals with alcohol dependence. Our analysis revealed the need for improving the availability and access to treatment, and enhancing public awareness for the same. Finally, use of stigmatizing words to describe people with alcohol use-related problems and direct breach of privacy indicated that there is a need for media reporting guidelines to use neutral language and to monitor the level of adherence with the existing guidelines.

Limitations

This study has several limitations. Firstly, the analysis was based on the English newspapers with online access. News reports published in regional languages were not reviewed for the content analysis. Nevertheless, a majority of the news items accessed and analysed were from the regional-section of national newspapers or regional newspapers. Secondly, our narrative was solely based on news reports, which might be biased because of its political predilections and financial conflicts of interest. However, we conducted an extensive newspaper survey and included all news items retrieved by our search. Thirdly, newspaper reports are not peer-reviewed literature and no causal inference should be drawn from the reports, such as an increase in the incidence of death by suicide might also be contributed by the financial burden, stress of the outbreak, or underlying mental illness. However, these reports suggested a trend, which should be subjected to scientific scrutiny in the future. Fourthly, by design, we reviewed the first one month of post-lockdown prohibition. In India, prohibition continued even after that. Although our thematic analysis captured the immediate effect of prohibition on public health and on other stakeholders it might have missed some delayed responses such as permitting alcohol sale through food-delivery mobile applications in a few states or opening of shops for limited hours in a few others.

Conclusion

The newspaper analysis indicated beneficial and harmful aspects of an unplanned and unprecedented alcohol prohibition during the lockdown. The absence of a national-level alcohol policy was made apparent by the reflexive, disconnected, and conflictual policy measures. The lack of a public health orientation to the policy augmented the harm. The sudden alcohol prohibition was, perhaps, a learning lesson for countries like India, which are yet to have a strong public health-oriented national alcohol policy and emphasized the need for a balanced approach aiming at the reduction of alcohol-related harm. Nevertheless, the harms, perceived from the media reports, should be balanced against the potential benefits of prohibition such as reduction of domestic violence and increased treatment seeking. Besides, one should exercise caution in drawing any firm conclusion from media reports, which are not considered to be a source of scientific evidence. A disproportionately higher reporting of harmful effects of alcohol prohibition could result from visibility or presentation bias of media reporting. Having said that, we believe, the analysis of newspaper reports underlined the possible areas for future research.

Declarations of Interests

None to declare.