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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.
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.
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.
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.
Keywords: Qualitative analysis, Alcohol, Prohibition, Policy, India, SARS-CoV-2According 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 et al., 2019). 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 et al., 2019; Benegal, 2005; Gaunekar et al., 2004; 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 et al., 2018). 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 et al., 2020; 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.
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.
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.
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
Ethical clearance was obtained from the All India Institute of Medical Sciences, Rishikesh, India- ethics committee (Ref: 54/02/PSY/2020–167).
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 ).