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What explanations for the Alcohol Harm Paradox are proposed in the literature? A Systematic Review - Final Protocol October 2019



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What explanation for the Alcohol Harm Paradox are proposed in the literature?
A Systematic Review.
Final Protocol: October 2019
Lead Investigator: Jennifer Boyd (
Co-investigators: Robin Purshouse, Colin Angus, Petra Meier, Olivia Sexton, John
Institution: ScHARR, University of Sheffield
1. Introduction
Alcohol is known to play a causal role in over 200 disease and injury conditions,
accounting for 5.3% of deaths and 5.1% of the burden of disease and injury globally
(1). There is evidence to suggest alcohol-related harm is not equitably distributed
across socioeconomic position (SEP). Disadvantaged groups in society
disproportionately suffer from alcohol related harm compared with advantaged
groups, despite reporting similar or lower levels of consumption (2,3). This consistent
finding has been termed the alcohol harm paradox (AHP) (4). Although previous
research has focused on establishing the existence of this phenomenon, there is a
paucity of evidence which attempts to understand the underlying causes.
Several reviews and meta-analyses have been published with a primary aim of
establishing socioeconomic differences in alcohol-related or attributable harms
based on existing evidence or available survey data (3,58). A subset also focused
on the role of levels or patterns of alcohol consumption (5,7,8). Overall, elevated risk
did exist for low SEP groups and differences in consumption could not completely
explain this relationship it did attenuate the relationship for some disease specific
outcomes (7). Each review discussed potential causes of the AHP, but this was often
brief. Therefore, scope exists to conduct a review which synthesizes causal
explanations for the AHP.
Previous research investigating the causes of the AHP has focused on
methodological and behavioural explanations. In terms of methodological
explanations, it is often argued that the AHP is the result of low SEP groups
underreporting their alcohol consumption (4). However, there is evidence to suggest
that high SEP groups also underreport their consumption (9). Therefore, it remains
unclear whether methodological issues are the cause. Cross-sectional studies have
empirically tested differences in drinking patterns, behavioural clustering, drinking
histories and underreporting between SEP groups (9,10). While average alcohol
consumption is similar or less (typically across the week or annually) for low SEP
groups, there is evidence that they tend to drink more per occasion (engaging in
binge drinking) and engage in multiple risky health behaviours (9,10) these studies
do not test harm outcomes. A more recent study highlighted that low SEP was
associated with elevated alcohol related harm relative to high SEP after adjusting for
weekly consumption, binge drinking, BMI, and smoking (11). Therefore, it is clear
behavioural factors do not adequately explain the AHP. Although behavioural factors
may play a role (4), other explanations have been neglected.
Given previous research has narrowly focused on using proximal individual-level
factors to explain the AHP, this review aimed to comprehensively identify proposed
explanations for the paradox used within the relevant literature. This literature
includes papers explicitly exploring the causes of the AHP, in addition to those
testing the relationship between SEP, consumption and harm. Secondary aims of the
review were to explore any relationships between these explanations and provide an
overview of the existing evidence for these explanations taken from the included
2. Detailed methodology
2.1 Rationale for literature review
The existing empirical evidence has been dominated by behavioural and
methodological explanations for the AHP, while wider determinants (e.g. living and
working conditions, social networks) have been largely ignored. Our review will
therefore consider explanations for the existence of the AHP not only tested in
empirical research but also those explored hypothetically in the discussion sections
of these papers and more broadly in secondary research, debate/discussion papers
and the grey literature. The key focus is on what has been suggested as an
explanation for the AHP from a wide range of literature.
2.2 Research aims and objectives
The primary aim of this review was to identify proposed explanations for the AHP
from the existing literature. Secondary aims were to understand the relationships
between these explanations and the provide an overview of the evidence base for
these explanations. This will be achieved through the following objectives:
1. To identify academic and grey literature which either a) discusses or
investigates the existence or explanations for the AHP or b) explores the
relationship between socioeconomic position (SEP), alcohol consumption and
alcohol-related harm.
2. Use thematic analysis to collate and summarise existing explanations
presented in the literature.
3. Assess whether explanations fit within wider domains and whether there are
relationships between explanations.
4. Summarise the evidence base for explanations which have been empirically
5. Discuss the findings of the review and consider any implications for future
research and policy, including how the findings should inform the alcohol-
harm research agenda.
2.3 Search Strategy
Academic Literature
A comprehensive search strategy will be implemented across 3 electronic
bibliographic databases: MEDLINE, EMBASE and PsycINFO. Two main blocks of
search terms will be used, one covering socioeconomic inequalities and the other
alcohol consumption (see Appendix A for list of search terms); eligible articles must
appear in both.
The results of a preliminary scoping searches in MEDLINE and PsycINFO are
displayed in Table 1 (search conducted in 05 October 2019). Given these findings,
this study will not restrict included papers to the UK setting given the aim of this
paper is to identify a broad range of explanations for the AHP, which is shown to not
only exist in the UK but also in other countries, for example Finland (12) and
Australia (13). However, when screening studies, only those set in the global north
as defined by the OECD (14) will be selected for full text screening. This is due to
stark differences in drinking culture between the global north and south.
Table 1: Search results for preliminary scoping searches
Search term blocks
UK only
Grey literature
Grey literature pertaining to this topic will be identified in three main ways. Firstly,
expert opinion will be solicited to identify key relevant papers. I will supplement the
database searches with searches of Google/Google Scholar using the search terms:
socioeconomic, inequalities, alcohol-related harm, deprivation, morbidity, mortality.
This will also include searching for reports on the websites of key organisations and
charities (e.g. Institute of Alcohol Studies UK, The Foundation for Alcohol Research
and Education (FARE) Australia).
2.4 Study eligibility criteria
Studies that meet this specified criterion will be eligible for inclusion:
Aim to investigate the existence and/or explanations for the alcohol harm
Any investigation of the relationship between alcohol related harm,
socioeconomic status, and alcohol consumption
o Any type of alcohol related physical health harm- morbidity and
mortality associated with alcohol use both wholly and partially
attributable causes and general physical health complaints -
o social harm (e.g. victimisation)
o clinical diagnosis of alcohol use disorder using ICD codes/ DSM-IV
o Any measure of socioeconomic status; deprivation score, education,
occupation, income, etc.
o Any measure of alcohol consumption
● Empirical studies: cross-sectional or longitudinal; or theoretical papers, or
commentaries and/or reports produced by agencies and organisations
● Full papers
Studies will be excluded if they meet any of the following criteria:
● Studies exclusively looking at countries outside of the global north as defined by
OECD (14)
● Non-English language papers
Treatment/Intervention studies
2.5 Literature Screening
Abstract and title screening will initially be undertaken by one reviewer (JB) to
identify relevant references which investigate the topic of socioeconomic inequalities
in alcohol-related harm (both explicitly and implicitly). Full paper screening will then
be conducted by the same reviewer (JB). This process will be done for both
academic and grey literature.
2.6 Data extraction and quality appraisal
A data extraction matrix has been developed with headings appropriate to the
research question. This was done in collaboration with co-authors (RP & JH). For
each included study, the following details will be extracted: Author, Year of
Publication, Country, Study Design, Year of data collection, Population, Sample size,
Unit of analyses (e.g. area level etc.), Age of participants, Hypothesis/Aim, Alcohol
harm measure, socioeconomic position measure, alcohol consumption measure,
evidence of the AHP (yes/no), main findings, how to the researchers attempt to
explain the AHP and theoretical propositions used to explain the AHP. The studies
will be quality appraised, the checklist used for this will depend on the study design,
for example cross-sectional studies will be appraised with the AXIS checklist (15).
Data extraction and quality appraisal will be undertaken by JB. An independent
reviewer (OS) will crosscheck a subset of included papers (approx. 20%) against
both the inclusion criteria and for extraction.
2.7 Approach to synthesis
Given that the research question is of a qualitative nature, we do not intend to
conduct a meta-analysis. Initially a narrative synthesis will be presented to gain an
understanding of the studies included in the review. To address Objective 2, a
thematic analysis will be conducted which aims to group the explanations into broad
themes. Any relationships between explanations (instances of authors combining or
relating explanations). Finally, a narrative synthesis will be presented which
summarises the findings from the studies which have empirically tested
explanations. Research cited within the included papers to support or oppose
explanations will also be synthesized.
3. Research Outputs
This systematic review will be submitted as an academic article to an academic
journal, expected submission date August 2020.
4. Timeline
Oct 2019: Finalise search strategy and data extraction/quality appraisal proforma
Oct-Nov 2020: Run systematic searches
Solicit expert opinion/online search for grey literature
Title/Abstract screening
Dec-Jan 2020: Full text screen for eligibility criteria
Data extraction and quality appraisal
Feb-Mar 2020: Data analysis and synthesis
Apr-Jul 2020: Prepare manuscript for publication
Jul 2020: Rerun systematic searches
Aug 2020: Submit paper for publication
1. World Health Organisation. Global status report on alcohol and health 2014. 2014;1
392. Available from:
2. Beard E, Brown J, West R, Angus C, Brennan A, Holmes J, et al. Deconstructing the
Alcohol Harm Paradox: A population based survey of adults in England. PLoS One.
3. Probst C, Roerecke M, Behrendt S, Rehm J. Socioeconomic differences in alcohol-
attributable mortality compared with all-cause mortality: A systematic review and
meta-analysis. Int J Epidemiol. 2014;43(4):131427.
4. Smith BK, Global R, Health P. Alcohol , Health Inequalities and the Harm Paradox :
Why some groups face greater problems despite consuming less alcohol A summary
of the available evidence. 2014;
5. Collins SE. Associations between socioeconomic factors and alcohol outcomes.
Alcohol Res Curr Rev. 2016;38(1):8394.
6. Probst C, Roerecke M, Behrendt S, Rehm J. Gender differences in socioeconomic
inequality of alcohol-attributable mortality: A systematic review and meta-analysis.
Drug Alcohol Rev. 2015;34(3):26777.
7. Jones L, Bates G, McCoy E, Bellis MA. Relationship between alcohol-attributable
disease and socioeconomic status, and the role of alcohol consumption in this
relationship: A systematic review and meta-analysis. BMC Public Health. 2015;15(1).
8. Grittner U, Kuntsche S, Graham K, Bloomfield K. Social inequalities and gender
differences in the experience of alcohol-related problems. Alcohol Alcohol.
9. Bellis MA, Hughes K, Nicholls J, Sheron N, Gilmore I, Jones L. The alcohol harm
paradox: Using a national survey to explore how alcohol may disproportionately
impact health in deprived individuals. BMC Public Health [Internet]. 2016;16(1):110.
Available from:
10. Lewer D, Meier P, Beard E, Boniface S, Kaner E. Unravelling the alcohol harm
paradox: A population-based study of social gradients across very heavy drinking
thresholds. BMC Public Health [Internet]. 2016;16(1):111. Available from:
11. Katikireddi SV, Whitley E, Lewsey J, Gray L, Leyland AH. Socioeconomic status as an
effect modifier of alcohol consumption and harm: analysis of linked cohort data.
Lancet Public Heal [Internet]. 2017;2(6):e26776. Available from:
12. Mäkelä P, Paljärvi T. Do consequences of a given pattern of drinking vary by
socioeconomic status? a mortality and hospitalisation follow-up for alcohol-related
causes of the Finnish Drinking Habits Surveys. J Epidemiol Community Health.
13. Livingston M. Socioeconomic differences in alcohol-related risk-taking behaviours.
Drug Alcohol Rev. 2014;33(6):58895.
14. World Bank Group. Fact Sheet: OECD High-Income. Doing Business. [Internet]. 2019
[cited 2019 Mar 9]. Available from:
15. Downes M, Brennan M, Williams H, Open RD-B, 2016 U. Development of a critical
appraisal tool to assess the quality of cross-sectional studies (AXIS). BMJ Open
[Internet]. 2016 [cited 2020 May 22];1;6(12). Available from:
Search terms
(.mp.) (MEDLINE &
Alcohol* adj3 drink*
Heavy adj3 drink*
Binge drink*
*alcohol consumption/ or
*binge drinking/ or
*heavy drinking
Alcohol (PsychInfo)
Alcohol* adj3 drink* (.mp.)
Alcohol drinking
Heavy adj3 drink* (.mp.)
*alcohol consumption/
OR *binge drinking/ OR
*heavy drinking/
Health Inequalities
Health Status Disparities/ or
exp Socioeconomic Factors/
Health adj2 inequalit*
Socioeconomic or socio-
economic (.mp.)
Health Inequalities
Health status disparities
Socioeconomic status/
Health adj2 inequalit*
Status (MEDLINE &
Disadvantage* OR inequit*
OR inequal* OR poverty OR
low income OR unemploy*
OR employ
High income OR
deprived OR social class
OR upper class OR
middle class OR working
Deprivation (.mp.)
Status (PsychInfo)
Disadvantage* OR inequit*
OR inequal* OR poverty OR
low income OR unemploy*
OR employ (.mp.)
High income OR
deprived OR social class
OR upper class OR
middle class OR working
class (.mp.)
Deprivation (.mp.)
*social class/ OR
*socioeconomic status/
Exclusions for:
MEDLINE & Embase
Therapeutics/ OR
psychotherapy/ OR
intervention.ti. OR brief
intervention.ab. OR
(Gestat* OR fet* OR
child* OR adolescen*
OR you* OR matern*
OR birth* OR parent*
OR preg* OR
(Brain OR bacter* OR
pathogen* OR methyl*
OR memor* OR cortex
OR neur* OR
(Africa* OR chin* OR
india* OR Russia* OR
thai* OR vietn* OR
Uganda OR brazil OR
Addiction.ti. OR OR
disorder.ti. OR psych*.ti.
Exclusions for:
(Addiction OR rehabilitation
OR alcoholi*).ti.
Therapeutics/ OR
psychotherapy/ OR
intervention.ti. OR brief
intervention.ab. OR
effectiveness.ti. OR
(Gestat* OR fetal OR
child* OR adolescen*
OR young OR matern*
OR birth* OR preg* OR
parent* OR school OR
ResearchGate has not been able to resolve any citations for this publication.
Full-text available
Objectives The aim of this study was to develop a critical appraisal (CA) tool that addressed study design and reporting quality as well as the risk of bias in cross-sectional studies (CSSs). In addition, the aim was to produce a help document to guide the non-expert user through the tool. Design An initial scoping review of the published literature and key epidemiological texts was undertaken prior to the formation of a Delphi panel to establish key components for a CA tool for CSSs. A consensus of 80% was required from the Delphi panel for any component to be included in the final tool. Results An initial list of 39 components was identified through examination of existing resources. An international Delphi panel of 18 medical and veterinary experts was established. After 3 rounds of the Delphi process, the Appraisal tool for Cross-Sectional Studies (AXIS tool) was developed by consensus and consisted of 20 components. A detailed explanatory document was also developed with the tool, giving expanded explanation of each question and providing simple interpretations and examples of the epidemiological concepts being examined in each question to aid non-expert users. Conclusions CA of the literature is a vital step in evidence synthesis and therefore evidence-based decision-making in a number of different disciplines. The AXIS tool is therefore unique and was developed in a way that it can be used across disciplines to aid the inclusion of CSSs in systematic reviews, guidelines and clinical decision-making.
Full-text available
Background: The Alcohol Harm Paradox refers to observations that lower socioeconomic status (SES) groups consume less alcohol but experience more alcohol-related problems. However, SES is a complex concept and its observed relationship to social problems often depends on how it is measured and the demographic groups studied. Thus this study assessed socioeconomic patterning of alcohol consumption and related harm using multiple measures of SES and examined moderation of this patterning by gender and age. Method: Data were used from the Alcohol Toolkit Study between March and September 2015 on 31,878 adults (16+) living in England. Participants completed the AUDIT which includes alcohol consumption, harm and dependence modules. SES was measured via qualifications, employment, home and car ownership, income and social-grade, plus a composite of these measures. The composite score was coded such that higher scores reflected greater social-disadvantage. Results: We observed the Alcohol Harm Paradox for the composite SES measure, with a linear negative relationship between SES and AUDIT-Consumption scores (β = -0.036, p<0.001) and a positive relationship between lower SES and AUDIT-Harm (β = 0.022, p<0.001) and AUDIT-Dependence (β = 0.024, p<0.001) scores. Individual measures of SES displayed different, and non-linear, relationships with AUDIT modules. For example, social-grade and income had a u-shaped relationship with AUDIT-Consumption scores while education had an inverse u-shaped relationship. Almost all measures displayed an exponential relationship with AUDIT-Dependence and AUDIT-Harm scores. We identified moderating effects from age and gender, with AUDIT-Dependence scores increasing more steeply with lower SES in men and both AUDIT-Harm and AUDIT-Dependence scores increasing more steeply with lower SES in younger age groups. Conclusion: Different SES measures appear to influence whether the Alcohol Harm Paradox is observed as a linear trend across SES groups or a phenomenon associated particularly with the most disadvantaged. The paradox also appears more concentrated in men and younger age groups.
Full-text available
Background There is consistent evidence that individuals in higher socioeconomic status groups are more likely to report exceeding recommended drinking limits, but those in lower socioeconomic status groups experience more alcohol-related harm. This has been called the ‘alcohol harm paradox’. Such studies typically use standard cut-offs to define heavy drinking, which are exceeded by a large proportion of adults. Our study pools data from six years (2008–2013) of the population-based Health Survey for England to test whether the socioeconomic distribution of more extreme levels of drinking could help explain the paradox. Methods The study included 51,498 adults from a representative sample of the adult population of England for a cross-sectional analysis of associations between socioeconomic status and self-reported drinking. Heavy weekly drinking was measured at four thresholds, ranging from 112 g+/168 g + (alcohol for women/men, or 14/21 UK standard units) to 680 g+/880 g + (or 85/110 UK standard units) per week. Heavy episodic drinking was also measured at four thresholds, from 48 g+/64 g + (or 6/8 UK standard units) to 192 g+/256 g + (or 24/32 UK standard units) in one day. Socioeconomic status indicators were equivalised household income, education, occupation and neighbourhood deprivation. Results Lower socioeconomic status was associated with lower likelihoods of exceeding recommended limits for weekly and episodic drinking, and higher likelihoods of exceeding more extreme thresholds. For example, participants in routine or manual occupations had 0.65 (95 % CI 0.57–0.74) times the odds of exceeding the recommended weekly limit compared to those in ‘higher managerial’ occupations, and 2.15 (95 % CI 1.06–4.36) times the odds of exceeding the highest threshold. Similarly, participants in the lowest income quintile had 0.60 (95 % CI 0.52–0.69) times the odds of exceeding the recommended weekly limit when compared to the highest quintile, and 2.30 (95 % CI 1.28–4.13) times the odds of exceeding the highest threshold. Conclusions Low socioeconomic status groups are more likely to drink at extreme levels, which may partially explain the alcohol harm paradox. Policies that address alcohol-related health inequalities need to consider extreme drinking levels in some sub-groups that may be associated with multiple markers of deprivation. This will require a more disaggregated understanding of drinking practices.
Full-text available
Socioeconomic status (SES) is one of the many factors influencing a person's alcohol use and related outcomes. Findings have indicated that people with higher SES may consume similar or greater amounts of alcohol compared with people with lower SES, although the latter group seems to bear a disproportionate burden of negative alcohol-related consequences. These associations are further complicated by a variety of moderating factors, such as race, ethnicity, and gender. Thus, among individuals with lower SES, members of further marginalized communities, such as racial and ethnic minorities and homeless individuals, experience greater alcohol-related consequences. Future studies are needed to more fully explore the underlying mechanisms of the relationship between SES and alcohol outcomes. This knowledge should be applied toward the development of multilevel interventions that address not only individual-level risks but also economic disparities that have precipitated and maintained a disproportionate level of alcohol-related consequences among more marginalized and vulnerable populations.
Full-text available
Internationally, studies show that similar levels of alcohol consumption in deprived communities (vs. more affluent) result in higher levels of alcohol-related ill health. Hypotheses to explain this alcohol harm paradox include deprived drinkers: suffering greater combined health challenges (e.g. smoking, obesity) which exacerbate effects of alcohol harms; exhibiting more harmful consumption patterns (e.g. bingeing); having a history of more harmful consumption; and disproportionately under-reporting consumption. We use a bespoke national survey to assess each of these hypotheses. A national telephone survey designed to test this alcohol harm paradox was undertaken (May 2013 to April 2014) with English adults (n = 6015). Deprivation was assigned by area of residence. Questions examined factors including: current and historic drinking patterns; combined health challenges (smoking, diet, exercise and body mass); and under-reported consumption (enhanced questioning on atypical/special occasion drinking). For each factor, analyses examined differences between deprived and more affluent individuals controlled for total alcohol consumption. Independent of total consumption, deprived drinkers were more likely to smoke, be overweight and report poor diet and exercise. Consequently, deprived increased risk drinkers (male >168-400 g, female >112-280 g alcohol/week) were >10 times more likely than non-deprived counterparts to drink in a behavioural syndrome combining smoking, excess weight and poor diet/exercise. Differences by deprivation were significant but less marked in higher risk drinkers (male >400 g, female >280 g alcohol/week). Current binge drinking was associated with deprivation independently of total consumption and a history of bingeing was also associated with deprivation in lower and increased risk drinkers. Deprived increased/higher drinkers are more likely than affluent counterparts to consume alcohol as part of a suite of health challenging behaviours including smoking, excess weight and poor diet/exercise. Together these can have multiplicative effects on risks of wholly (e.g. alcoholic liver disease) and partly (e.g. cancers) alcohol-related conditions. More binge drinking in deprived individuals will also increase risks of injury and heart disease despite total alcohol consumption not differing from affluent counterparts. Public health messages on how smoking, poor diet/exercise and bingeing escalate health risks associated with alcohol are needed, especially in deprived communities, as their absence will contribute to health inequalities.
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Studies show that alcohol consumption appears to have a disproportionate impact on people of low socioeconomic status. Further exploration of the relationship between alcohol consumption, socioeconomic status and the development of chronic alcohol-attributable diseases is therefore important to inform the development of effective public health programmes. We used systematic review methodology to identify published studies of the association between socioeconomic factors and mortality and morbidity for alcohol-attributable conditions. To attempt to quantify differences in the impact of alcohol consumption for each condition, stratified by SES, we (i) investigated the relationship between SES and risk of mortality or morbidity for each alcohol-attributable condition, and (ii) where, feasible explored alcohol consumption as a mediating or interacting variable in this relationship. We identified differing relationships between a range of alcohol-attributable conditions and socioeconomic indicators. Pooled analyses showed that low, relative to high socioeconomic status, was associated with an increased risk of head and neck cancer and stroke, and in individual studies, with hypertension and liver disease. Conversely, risk of female breast cancer tended to be associated with higher socioeconomic status. These findings were attenuated but held when adjusted for a number of known risk factors and other potential confounding factors. A key finding was the lack of studies that have explored the interaction between alcohol-attributable disease, socioeconomic status and alcohol use. Despite some limitations to our review, we have described relationships between socioeconomic status and a range of alcohol-attributable conditions, and explored the mediating and interacting effects of alcohol consumption where feasible. However, further research is needed to better characterise the relationship between socioeconomic status alcohol consumption and alcohol-attributable disease risk so as to gain a greater understanding of the mechanisms and pathways that influence the differential risk in harm between people of low and high socioeconomic status.
Full-text available
Factors underlying socioeconomic inequalities in mortality are not well understood. This study contributes to our understanding of potential pathways to result in socioeconomic inequalities, by examining alcohol consumption as one potential explanation via comparing socioeconomic inequalities in alcohol-attributable mortality and all-cause mortality. Web of Science, MEDLINE, PsycINFO and ETOH were searched systematically from their inception to second week of February 2013 for articles reporting alcohol-attributable mortality by socioeconomic status, operationalized by using information on education, occupation, employment status or income. The sex-specific ratios of relative risks (RRRs) of alcohol-attributable mortality to all-cause mortality were pooled for different operationalizations of socioeconomic status using inverse-variance weighted random effects models. These RRRs were then combined to a single estimate. We identified 15 unique papers suitable for a meta-analysis; capturing about 133 million people, 3 741 334 deaths from all causes and 167 652 alcohol-attributable deaths. The overall RRRs amounted to RRR = 1.78 (95% confidence interval (CI) 1.43 to 2.22) and RRR = 1.66 (95% CI 1.20 to 2.31), for women and men, respectively. In other words: lower socioeconomic status leads to 1.5-2-fold higher mortality for alcohol-attributable causes compared with all causes. Alcohol was identified as a factor underlying higher mortality risks in more disadvantaged populations. All alcohol-attributable mortality is in principle avoidable, and future alcohol policies must take into consideration any differential effect on socioeconomic groups.
Full-text available
To examine the influence of country-level characteristics and individual socio-economic status (SES) on individual alcohol-related consequences. Data from 42,655 men and women collected by cross-sectional surveys in 25 countries of the Gender, Alcohol and Culture: An International Study study were used. The individual SES was measured by the highest attained educational level. Alcohol-related consequences were defined as the self-report of at least one internal or one external consequence in the last year. The relationship between individuals' education and alcohol-related consequences was examined by meta-analysis. In a second step, the individual level data and country data were combined in multilevel models. As country-level indicators, we used the purchasing power parity of the gross national income (GNI), the Gini coefficient and the Gender Gap Index. Lower educated men and women were more likely to report consequences than higher educated men and women even after controlling for drinking patterns. For men, this relation was significant for both internal and external problems. For women, it was only significant for external problems. The GNI was significantly associated with reporting external consequences for men such that in lower income countries men were more likely to report social problems. The fact that problems accrue more quickly for lower educated persons even if they drink in the same manner can be linked to the social or environmental dimension surrounding problems. That is, those of fewer resources are less protected from the experience of a problem or the impact of a stressful life event.
Introduction and aims: There is substantial research showing that low socioeconomic position is a predictor of negative outcomes from alcohol consumption, while alcohol consumption itself does not exhibit a strong social gradient. This study aims to examine socioeconomic differences in self-reported alcohol-related risk-taking behaviour to explore whether differences in risk-taking while drinking may explain some of the socioeconomic disparities in alcohol-related harm. Design and methods: Cross-sectional data from current drinkers (n = 21 452) in the 2010 wave of the Australian National Drug Strategy Household Survey were used. Ten items on risk-taking behaviour while drinking were combined into two risk scores, and zero-inflated Poisson regression was used to assess the relationship between socioeconomic position and risk-taking while controlling for age, sex and alcohol consumption. Results: Socioeconomically advantaged respondents reported substantially higher rates of alcohol-related hazardous behaviour than socioeconomically disadvantaged respondents. Controlling for age, sex, volume of drinking and frequency of heavy drinking, respondents living in the most advantaged quintile of neighbourhoods reported significantly higher rates of hazardous behaviour than those in the least advantaged quintile. A similar pattern was evident for household income. Discussion and conclusions: Socioeconomically advantaged Australians engage in alcohol-related risky behaviour at higher rates than more disadvantaged Australians even with alcohol consumption controlled. The significant socioeconomic disparities in negative consequences linked to alcohol consumption cannot in this instance be explained via differences in behaviour while drinking. Other factors not directly related to alcohol consumption may be responsible for health inequalities in outcomes with significant alcohol involvement.
Introduction and AimsThe present analysis contributes to understanding the societal distribution of alcohol-attributable harm by investigating socioeconomic inequality and related gender differences in alcohol-attributable mortality.Design and MethodsA systematic literature search was performed on Web of Science, MEDLINE, PsycINFO and ETOH from their inception until February 2013. Articles were included when they reported data on alcohol-attributable mortality by socioeconomic status (SES), operationalised as education, occupation, employment status or income. Gender-specific relative risks (RR) comparing low with high SES were pooled using random effects meta-analyses. Gender differences were additionally investigated in random effects meta-regressions.ResultsNineteen articles from 14 countries were included. For women, significant RRs across all measures of SES, except employment status, were found, ranging between 1.75 [95% confidence interval (CI) 1.21–2.54; occupation] and 4.78 (95% CI 2.57–8.87; income). For men, all measures of SES showed significant RRs ranging between 2.88 (95% CI 2.45–3.40; income) and 12.25 (95% CI 11.45–13.10; employment status). While RRs for men were in general slightly higher, only for occupation this gender difference was above chance (P = 0.01). Results refer to deaths 100% attributable to alcohol.Discussion and Conclusions The results are predominantly based on data from high-income countries, limiting generalisability. Alcohol-attributable mortality is strongly distributed to the disadvantage of persons with a low SES. Marked gender differences in this inequality were found for occupation. Possibly male-dominated occupations of low SES were more strongly related to risky drinking cultures compared with female-dominated occupations of the same SES.