Risk Pathways Contributing to the Alcohol Harm Paradox: Socioeconomic Deprivation Confers Susceptibility to Alcohol Dependence via Greater Exposure to Aversive Experience, Internalizing Symptoms and Drinking to Cope

Abstract

Socioeconomic deprivation is associated with greater alcohol problems despite lower alcohol consumption, but the mechanisms underpinning this alcohol harm paradox remain obscure. Fragmented published evidence collectively supports a multistage causal risk pathway wherein socioeconomic deprivation increases the probability of exposure to aversive experience, which promotes internalizing symptoms (depression and anxiety), which promotes drinking alcohol to cope with negative affect, which in turn accelerates the transition from alcohol use to dependence. To evaluate this proposed risk pathway, 219 hazardous drinkers from an undergraduate population completed questionnaires assessing these constructs in a single, cross sectional, online survey. Partial correlation coefficients revealed that each variable showed the strongest unique association with the next variable in the proposed multistage model, when adjusting for the other variables. Bootstrapped serial mediation analysis revealed that the indirect pathway linking all the variables in the proposed serial order was significant, while all other permutations were non-significant. Network centrality analysis corroborated the serial order of this indirect path. Finally, risk ratios estimated by categorizing the variables suggested that socioeconomic deprivation increased the risk of aversive experience by 32%, which increased the risk of internalizing symptoms by 180%, which increased the risk of drinking to cope by 64%, which increased susceptibility to alcohol dependence by 59%. These preliminary findings need to be corroborated by future research, nevertheless, they call for prevention strategies founded on social justice and the minimization of aversive experience in socially deprived individuals to mitigate mental health problems, maladaptive coping and addiction.

The direct effect of drinking to cope on alcohol problems is not mediated by alcohol consumption: Invariance across gender and countries

“…Frequent alcohol consumption in early adolescence is a strong prospective predictor of alcohol problems (negative consequences and dependence) in later life ( Heron et al, 2012 , Percy and Iwaniec, 2007 ). However, alcohol consumption does not explain all the variance in alcohol problems ( Prince et al, 2018 ), suggesting that additional individual difference variables confer unique risk of developing alcohol problems independently of consumption – the so-called alcohol harm paradox ( Boyd et al, 2022 , Shuai et al, 2022 ). Motivational theories of addiction have generated evidence that drinking to cope with negative affect is uniquely associated with alcohol problems but not with greater alcohol consumption, whereas conversely, self-reported drinking to enhance positive experience is uniquely associated with greater alcohol consumption but not with alcohol problems ( Anderson et al, 2013 , Cooper, 1994 , Cooper et al, 1995 , Cox and Klinger, 1988 , Kassel et al, 2000 , Kuntsche et al, 2005 , Merrill and Read, 2010 , Molnar et al, 2010 , Read et al, 2003 , Simons et al, 2005 , Watkins et al, 2015 ; for a meta-analysis of 28 association studies see Cooper et al, 2016 ).…”

Alcohol and Public Health: Failure and Opportunity

“…This relationship has been demonstrated on a range of axes: from gender to race to social class. The paradox has roots in individual behavioral strategies but also in structural elements of low‐income and marginalized communities in the United States 57 . A growing literature has documented alcohol's historic role in establishing and perpetuating inequity by neighborhood: a history of redlining by government and banks contributed to overconcentration of alcohol outlets and attendant problems, including notably violent crime, in poor and historically discriminated against racial and ethnic communities across the United States 58–60 .…”

“…The paradox has roots in individual behavioral strategies but also in structural elements of low-income and marginalized communities in the United States. 57 A growing literature has documented alcohol's historic role in establishing and perpetuating inequity by neighborhood: a history of redlining by government and banks contributed to overconcentration of alcohol outlets and attendant problems, including notably violent crime, in poor and historically discriminated against racial and ethnic communities across the United States. [58][59][60] At the same time, the failure of alcohol taxes to keep pace with inflation, the thorough penetration of alcohol marketing into genres popular in marginalized communities such as rap and hip-hop, and the creation and proliferation of high-alcohol products targeted at those communities combine to saturate populations already at risk from poverty and lack of access to health care with a steady supply of cheap alcohol.…”

Comorbid posttraumatic stress disorder and alcohol use disorder in low- and middle-income countries: A narrative review

“…The models of PTSD + AUD comorbidity have largely been developed in HIC settings and may not encompass other potential explanatory mechanisms (Shuai et al, 2022 ). Models of broad relevance to LMIC settings may further be limited by the fact that, as previously discussed, prior examinations of PTSD + AUD in LMICs have focused on specific, at-risk groups rather than population-level data.…”