Who Drank and Used Cannabis More During COVID-19? Income and Identity Both Played a Role
Who Drank and Used Cannabis More During COVID-19? Income and Identity Both Played a Role
A Canadian intersectional study of nearly 9,000 adults finds that the pandemic’s impact on substance use was shaped not just by household wealth, but by the interplay of gender, ethnoracial background, and age, suggesting that single-axis public health approaches may miss the populations most at risk.
Why This Matters
The COVID-19 pandemic triggered well-documented increases in alcohol and cannabis use across many populations, but early research tended to examine risk factors in isolation, asking whether income or employment status alone predicted heavier use. This approach obscures the reality that socio-economic circumstances do not operate identically across gender, race, and age. As public health systems develop post-pandemic substance use interventions, understanding who was most affected and why requires a more layered analysis. This study attempts exactly that, arriving at a moment when pandemic-era drinking and cannabis patterns appear to be persisting in some populations.
Clinical Summary
Alcohol and cannabis use shifted substantially during the COVID-19 pandemic, but the direction and magnitude of those shifts were not uniform across social groups. Platt and colleagues, publishing in BMC Public Health in 2024, conducted a repeated cross-sectional study using nine consecutive web-based surveys of Canadian adults collected between May 2020 and January 2022. The study examined how three markers of socio-economic status, specifically household income, education level, and employment status, were associated with heavy episodic drinking, past-week cannabis use, and self-reported perceived increases in both substances. Crucially, the study went beyond simple main effects by incorporating interaction terms for gender, ethnoracial background, and age to test whether SES-substance use relationships varied across intersecting social identities.
The key findings revealed meaningful heterogeneity beneath aggregate patterns. Higher household income and unemployment were independently associated with heavy episodic drinking and perceived increases in alcohol use. However, intersectional analyses showed that racial and ethnic minority individuals with moderate incomes ($40,000 to $79,999) had greater odds of heavy episodic drinking than low-income White persons, while women and adults aged 40 to 59 with high incomes were more likely to report increased alcohol consumption than low-income men and younger adults. University education consistently protected against heavy episodic drinking and increased cannabis use, particularly among women and racial and ethnic minority groups. The authors acknowledge that the web-based panel sampling, reliance on self-reported perceived change, and use of stepwise regression limit the precision and generalizability of these intersectional estimates, and they call for longitudinal research with pre-registered intersectional hypotheses.
Dr. Caplan’s Take
This study asks the right question at the right time. We already knew that pandemic stress drove substance use upward for many people, but the idea that income, race, gender, and age interact to shape that risk is something clinicians encounter daily yet rarely see reflected in research. When a patient tells me they started drinking more during lockdown, the clinical picture is never just about their paycheck or their job status. It is about the totality of their social position. What this study does well is surface those interactions. What it cannot do, given its cross-sectional design and methodological limitations, is tell us precisely how large those effects are or whether they are causal.
In practice, I use findings like these to sharpen my screening conversations. When I see a middle-aged woman with moderate-to-high income who picked up heavier drinking during the pandemic, I do not assume her financial stability is protective. I ask directly about quantity, frequency, and perceived change. For patients from racial and ethnic minority backgrounds, I am especially attentive to the possibility that moderate income has not buffered substance use risk the way we might assume. The clinical takeaway is not a new protocol but a more honest, individualized approach to screening that accounts for intersecting vulnerabilities rather than relying on income as a shorthand for resilience.
Clinical Perspective
This study sits at an important juncture in the pandemic substance use literature. Early pandemic research relied heavily on single-wave, single-axis analyses that identified broad SES gradients. Platt and colleagues extend that work by covering four pandemic waves and explicitly modeling intersectional interactions. The finding that moderate-income racial and ethnic minority individuals had elevated odds of heavy episodic drinking compared to low-income White persons challenges the conventional gradient assumption that higher income uniformly protects against harmful use. For clinicians, this means that SES-based risk stratification alone is insufficient. The evidence does not yet support specific clinical protocols for intersecting subgroups, but it does justify more nuanced screening approaches that consider social identity alongside economic indicators.
From a pharmacological and safety standpoint, these findings are most relevant to clinicians managing patients who may have developed or escalated problematic drinking or cannabis use patterns during the pandemic and have not returned to pre-pandemic baselines. Heavy episodic drinking carries well-established risks for hepatic function, cardiovascular events, and interactions with common medications including benzodiazepines, anticoagulants, and certain antidepressants. Cannabis use escalation raises concerns about cognitive effects and interactions with CNS depressants. The single most actionable recommendation from this evidence is to incorporate brief intersectional screening into routine substance use assessments, specifically asking about pandemic-era changes in use and not assuming that higher-income or employed patients are at lower risk.
What Kind of Evidence Is This
This is an original quantitative research article using a repeated cross-sectional design with nine survey waves collected from a web-based panel of Canadian adults. In the evidence hierarchy, repeated cross-sectional studies sit below longitudinal cohort studies and randomized trials because they sample different participants at each wave, precluding individual-level tracking of change over time. The single most important inference constraint is that these findings are associational: the design cannot establish whether changes in SES caused changes in substance use, nor can it rule out unmeasured confounders driving observed relationships.
How This Fits With the Broader Literature
This study confirms and extends earlier pandemic substance use research, including work by Wardell and colleagues (2020) and the CAMH national survey series, which documented increases in alcohol and cannabis use during early lockdowns but typically examined SES indicators in isolation. The intersectional findings align with pre-pandemic health disparities research showing that income gradients in substance use outcomes are not uniform across racial and ethnic groups. The study also resonates with work by Collins (2019) on intersectionality in public health, which argues that additive models of social determinants miss important effect modification.
Where this study departs from prior work is in explicitly operationalizing intersectionality through statistical interaction terms rather than simply stratifying by one demographic variable at a time. This approach is conceptually stronger, though the relatively small subgroup sizes within intersecting categories mean that the specific point estimates should be treated as hypothesis-generating rather than definitive.
Common Misreadings
The most likely overinterpretation is to conclude that moderate income causes heavier drinking among racial and ethnic minority individuals or that high income causes increased alcohol use among women. The study identifies associations, not causal pathways. The cross-sectional design, web-based convenience sampling, and use of stepwise regression, which is known to inflate Type I error and produce unstable variable selection, all constrain the reliability of specific subgroup estimates. Readers should also avoid generalizing these Canadian findings directly to other national contexts, where the pandemic’s economic impacts, substance use norms, and ethnoracial composition differ substantially.
Bottom Line
This study provides useful evidence that socio-economic status alone is an incomplete lens for understanding pandemic-era substance use patterns. Its intersectional approach reveals that gender, ethnoracial background, and age modify the relationship between income and drinking or cannabis use in ways that single-axis analyses miss. However, the cross-sectional design, self-reported outcomes, and methodological limitations of stepwise regression mean these findings are best understood as hypothesis-generating. Clinicians should use them to inform more nuanced screening conversations rather than to justify specific subgroup-targeted interventions.
Frequently Asked Questions
Does this study prove that higher income leads to more drinking during a pandemic?
No. The study found an association between higher household income and heavier episodic drinking, but because of its cross-sectional design, it cannot determine whether income itself caused the increase. Other factors that tend to accompany higher income, such as greater disposable spending on alcohol, social norms in higher-income networks, or different types of pandemic-related stress, could be driving the relationship.
Why would racial and ethnic minority individuals with moderate incomes drink more heavily than lower-income White individuals?
The study identified this pattern but cannot fully explain it. Possible contributing factors include the compounding effects of racial discrimination alongside moderate economic resources, the psychological burden of being in a socio-economic position that is neither fully secure nor fully supported by safety-net programs, and differential exposure to pandemic-related occupational and community stressors. These hypotheses require further research to confirm.
Should I be concerned if my drinking increased during the pandemic and has not returned to previous levels?
Persistent increases in alcohol consumption after the acute pandemic period have been documented in multiple studies and are worth discussing with a healthcare provider. Even modest sustained increases in drinking carry cumulative health risks. A brief conversation with your clinician about current quantity, frequency, and any related concerns is a reasonable and low-barrier first step.
Does a university education actually protect against substance use problems?
In this study, university-level education was associated with lower odds of heavy episodic drinking and increased cannabis use, particularly among women and racial and ethnic minority individuals. However, education is a marker for many correlated factors, including health literacy, social networks, and access to coping resources. It would be inaccurate to say education directly prevents substance use problems, but the association is consistent with broader public health literature linking educational attainment to healthier behaviors.
Can these Canadian findings be applied to populations in other countries?
Caution is warranted. Canada has specific pandemic policy responses, healthcare structures, cannabis legalization
Have thoughts on this? Share it:
