Alcohol consumption, wealth, and health – Authors' reply
Authors: Srinivasa Vittal Katikireddi, Elise Whitley, Jim Lewsey, Alastair H Leyland
Journal: The Lancet Public Health (2017)

We thank Martin Frisher for his Correspondence about our Article,1Katikireddi 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 Health. 2017; 2: e267-e276Summary Full Text Full Text PDF PubMed Scopus (172) Google Scholar in which we used linked data to investigate the alcohol harms paradox. We found that increased alcohol consumption was associated with greater harms attributable to alcohol, but that populations of low socioeconomic status (measured by area-based deprivation, income, educational attainment, and social class) were disproportionately affected by alcohol-attributable harm. We found this disparity to be the case even when adjusting for differences in binge drinking, smoking, and body-mass index. We took advantage of the longitudinal nature of our data by excluding people who had a history of alcohol-related and drug-related harm and testing whether our results could be accounted for by social drift (ie, people becoming poor as a result of high-risk alcohol consumption), which we found they could not. Frisher stated that “alcohol use does not necessarily correspond to adverse health outcomes”. Although he referred to results for self-rated general health, our results showed that alcohol consumption was clearly associated with increased risk of alcohol-attributable harms. The most socially advantaged might be at less risk of harm, but consumption across the socioeconomic spectrum still carries a health risk and our findings in no way suggest otherwise. Although we appreciate that other cross-sectional research investigating self-reported outcomes might find less evidence of harm, our study aligns with the wealth of evidence showing the substantial health burdens that arise from alcohol consumption.2Babor T Caetano R Casswell S et al.Alcohol: no ordinary commodity. Research and public policy. 2nd edn. Oxford University Press, Oxford2010Crossref Scopus (2158) Google Scholar Furthermore, the public health message is now far clearer as a result of more causal analyses—in particular, Mendelian randomisation approaches have found no cardiovascular risk protection with low levels of alcohol consumption.3Holmes MV Dale CE Zuccolo L et al.Association between alcohol and cardiovascular disease: Mendelian randomisation analysis based on individual participant data.BMJ. 2014; 349: g4164Crossref PubMed Scopus (467) Google Scholar Therefore, we feel that the implications for public health are very clear: alcohol is a cause of harm to populations globally and evidence-based actions to address this burden need to be fully implemented. Our study also has implications for the understanding that public health policy makers have of health inequalities. Policies that reduce alcohol consumption across society are likely to disproportionately benefit the poorest in society. It is sometimes suggested that price-based measures (such as taxation or minimum unit pricing) impose greater financial costs on the poorest in society,4Katikireddi SV Bond L Hilton S Changing policy framing as a deliberate strategy for public health advocacy: a qualitative policy case study of minimum unit pricing of alcohol.Milbank Q. 2014; 92: 250-283Crossref PubMed Scopus (60) Google Scholar but our study suggests that their health is likely to benefit the most. Although addressing behavioural risk factors is important to improve population health, this strategy is unlikely to be sufficient to address socioeconomic inequalities in health. There is a continuing need to also focus on addressing underlying social inequalities. We declare no competing interests. Socioeconomic status as an effect modifier of alcohol consumption and harm: analysis of linked cohort dataDisadvantaged 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. Full-Text PDF Open AccessAlcohol consumption, wealth, and healthIn their Article, Srinivasa Vittal Katikireddi and colleagues1 report an analysis of the Scottish Health Surveys and suggest that “alcohol-attributable harms are far higher in disadvantaged social groups” but that “adjustment for alcohol consumption and binge drinking had little effect on the magnitude of the associations seen”. It is interesting to view these findings alongside those from the ELSA study, which found that, among people aged 50 years or older, the “level of alcohol consumption is not associated with self-rated health” and “rates of poor self-rated health among non-drinkers were significantly higher than the rates…for any of the groups who reported alcohol consumption”. Full-Text PDF Open Access