Socioeconomic status as an effect modifier of alcohol consumption and harm: analysis of linked cohort data

Abstract

SummaryBackgroundAlcohol-related mortality and morbidity are high in socioeconomically disadvantaged populations compared with individuals from advantaged areas. It is unclear if this increased harm reflects differences in alcohol consumption between these socioeconomic groups, reverse causation (ie, downward social selection for high-risk drinkers), or a greater risk of harm in individuals of low socioeconomic status compared with those of higher status after similar consumption. We aimed to investigate whether the harmful effects of alcohol differ by socioeconomic status, accounting for alcohol consumption and other health-related factors.MethodsThe Scottish Health Surveys are record-linked cross-sectional surveys representative of the adult population of Scotland. We obtained baseline demographics and data for alcohol consumption (units per week and binge drinking) from Scottish Health Surveys done in 1995, 1998, 2003, 2008, 2009, 2010, 2011, and 2012. We matched these data to records for deaths, admissions, and prescriptions. The primary outcome was alcohol-attributable admission or death. The relation between alcohol-attributable harm and socioeconomic status was investigated for four measures (education level, social class, household income, and area-based deprivation) using Cox proportional hazards models. The potential for alcohol consumption and other risk factors (including smoking and body-mass index [BMI]) mediating social patterning was explored in separate regression models. Reverse causation was tested by comparing change in area deprivation over time.Findings50 236 participants (21 777 men and 28 459 women) were included in the analytical sample, with 429 986 person-years of follow-up. Low socioeconomic status was associated consistently with strikingly raised alcohol-attributable harms, including after adjustment for weekly consumption, binge drinking, BMI, and smoking. Evidence was noted of effect modification; for example, relative to light drinkers living in advantaged areas, the risk of alcohol-attributable admission or death for excessive drinkers was increased (hazard ratio 6·12, 95% CI 4·45–8·41 in advantaged areas; and 10·22, 7·73–13·53 in deprived areas). We found little support for reverse causation.InterpretationDisadvantaged social groups have greater alcohol-attributable harms compared with individuals from advantaged areas for given levels of alcohol consumption, even after accounting for different drinking patterns, obesity, and smoking status at the individual level.FundingMedical Research Council, NHS Research Scotland, Scottish Government Chief Scientist Office.

Socioeconomic inequalities in alcohol use and some related consequences from a household perspective in Vietnam

“…For alcohol‐ related harms , our finding is consistent with the common trend that lower SES (living‐standard or education) is associated with highly increased consequence . The higher living‐standard status may provide the families more social buffers that could protect them from these harms .…”

Forecasting the 2021 local burden of population alcohol‐related harms using Bayesian structural time–series

“…However, recent evidence suggests that alcoholattributable hospital admissions and mortality remain higher among individuals from disadvantaged areas, even after controlling for differences in alcohol consumption, smoking and body mass index [28]. However, a recent study found no evidence of selective migration to more disadvantaged areas among high-risk drinkers [28]. However, a recent study found no evidence of selective migration to more disadvantaged areas among high-risk drinkers [28].…”

“…Existing evidence indicates that these disparities cannot be explained by differences in alcohol consumption alone Forecasting alcohol-related harms 999 and, thus, this inequality is often referred to as the 'alcohol harm paradox' [27]. Several explanations have been proposed to account for this apparent inequality, including the fact that individuals of lower socio-economic status are more likely to experience concurrent exposure to multiple adverse behavioural risk factors (such as poorer nutrition, lower levels of exercise, greater levels of smoking and obesity), as well as barriers to accessing health-care, which may exacerbate the adverse health effects of alcohol [27,28]. However, recent evidence suggests that alcoholattributable hospital admissions and mortality remain higher among individuals from disadvantaged areas, even after controlling for differences in alcohol consumption, smoking and body mass index [28].…”

“…Several explanations have been proposed to account for this apparent inequality, including the fact that individuals of lower socio-economic status are more likely to experience concurrent exposure to multiple adverse behavioural risk factors (such as poorer nutrition, lower levels of exercise, greater levels of smoking and obesity), as well as barriers to accessing health-care, which may exacerbate the adverse health effects of alcohol [27,28]. However, recent evidence suggests that alcoholattributable hospital admissions and mortality remain higher among individuals from disadvantaged areas, even after controlling for differences in alcohol consumption, smoking and body mass index [28]. A further proposed explanation is reverse causation due to downward social selection, whereby individuals with hazardous alcohol use are more likely to move to deprived areas.…”

Socioeconomic status and susceptibility to alcohol-related harm

“…In The Lancet Public Health, Vittal Katikireddi and colleagues 4 assess explanations of the alcohol harm paradox in a study that linked self-reported alcohol use in a series of large Scottish population surveys undertaken between 1995 and 2012 with health records of treated morbidity and mortality related to alcohol. 5 They gathered detailed data for alcohol use, socioeconomic status, and major risk factors for premature death and morbidity from very large, reasonably representative samples of Scottish adults.…”