Unravelling the alcohol harm paradox: a population-based study of social gradients across very heavy drinking thresholds

Abstract

BackgroundThere 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.MethodsThe 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.ResultsLower 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.ConclusionsLow 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.

Socioeconomic status and susceptibility to alcohol-related harm

“…Katikireddi and colleagues' findings also agree with those from other similar studies 6 in identifying alcohol use as a major contributor to social differentials in life expectancy and disease in developed societies.…”

The effect of socioeconomic deprivation on the association between an extended measurement of unhealthy lifestyle factors and health outcomes: a prospective analysis of the UK Biobank cohort

“…5 Similarly, deprived populations are disproportionately affected by the harmful effects of smoking and physical inactivity. 6,7 Mechanisms underlying this disproportion ate lifestyle harm remain unclear but might include extremes of unhealthy lifestyle factors, 8 interactions with other factors associated with deprivation (such as psychosocial stress), 9 and reduced access to health services. 10 However, previous studies of interactions between lifestyle factors and deprivation have examined only smoking, alcohol intake, and physical inactivity.…”

Texting to Reduce Alcohol Misuse (TRAM): main findings from a randomized controlled trial of a text message intervention to reduce binge drinking among disadvantaged men

“…The risk of alcohol‐related harm is highest among disadvantaged groups , making alcohol a major contributor to inequalities in health . This may be explained partially by patterns of drinking; socially disadvantaged individuals may not drink more on average, but they are more likely to binge drink . The group who binge drink most frequently in the United Kingdom comprises young to middle‐aged disadvantaged men .…”

“…This may be explained partially by patterns of drinking; socially disadvantaged individuals may not drink more on average, but they are more likely to binge drink . The group who binge drink most frequently in the United Kingdom comprises young to middle‐aged disadvantaged men . There is a need for interventions which access and engage meaningfully with this hard‐to‐reach population.…”