Understanding the alcohol-harm paradox: what next?
Authors: Kim Bloomfield
Journal: The Lancet Public Health (2020)

The alcohol-harm paradox (ie, the observation that people of low socioeconomic status (SES) tend to experience greater alcohol-related harm than those of high SES, even when the amount of alcohol consumption is the same or less than for individuals of high SES) continues to challenge epidemiologists and other public health experts. In the era of growing income inequalities worldwide, there is also concern as to how these increasing economic gaps affect health, including health risk behaviours.1Truesdale BC Jencks C The health effects of income inequality: averages and disparities.Annu Rev Public Health. 2016; 37: 413-430Crossref Scopus (64) Google Scholar To better understand the current evidence on the role of alcohol in socioeconomic health inequalities, Charlotte Probst and colleagues2Probst C Kilian C Sanchez S Lange S Rehm J The role of alcohol use and drinking patterns in socioeconomic inequalities in mortality: a systematic review.Lancet Public Health. 2020; 5: e324-e332Summary Full Text Full Text PDF PubMed Scopus (65) Google Scholar did a systematic review of studies that examined two potential explanatory mechanisms: (1) the differences in the volume and patterns of alcohol consumption between SES groups, and (2) an interactive or modifying effect of SES and alcohol consumption. The work updates and extends a previous systematic review of the alcohol harm paradox published in 2015.3Jones 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: 400Crossref PubMed Scopus (101) Google Scholar Probst and colleagues found that the greatest difference in harms between low and high SES was for heavy episodic drinking (or risky single occasion drinking), rather than for the mean quantity consumed per month or week. Additionally, they found suggestive evidence for a multiplicative effect between SES and alcohol consumption, which would imply that higher alcohol consumption poses disproportionately greater health risks for individuals with low SES than for those with high SES. On the basis of the findings of this systematic review, it could be argued that addressing the so-called alcohol-harm paradox requires public health programmes and legal policies that reduce the prevalence or frequency of heavy episodic drinking among individuals with low SES. However, it should be noted that in the literature reviewed by Probst and colleagues, drinking patterns explained a maximum of 30% of the variability in alcohol harm between socioeconomic groups. This value could partially be explained by an under-reporting of alcohol consumption by participants in the reviewed studies. Nevertheless, it is clear that substantial variability in alcohol-related harms between SES groups cannot be explained by drinking patterns alone. In a seminal book, Krieger4Krieger N Epidemiology and the people's health: theory and context. Oxford University Press, New York2011Crossref Scopus (500) Google Scholar emphasises the need to consider a so-called eco-social perspective to achieve a better understanding of contemporary determinants of health. Furthermore, Krieger and Davey Smith5Krieger N Davey Smith G The tale wagged by the DAG: broadening the scope of causal inference and explanation for epidemiology.Int J Epidemiol. 2016; 45: 1787-1808PubMed Google Scholar call for a more pluralistic view of causality—an approach that takes into account important contextual factors in addition to the purported agent (here, alcohol). In answering the question of why to consider inclusion of poverty as a confounder in epidemiological research, Krieger6Krieger N Why epidemiologists cannot afford to ignore poverty.Epidemiology. 2007; 18: 658-663Crossref PubMed Scopus (81) Google Scholar states: "many of the exposures epidemiologists are interested in coexist and are jointly embodied – not necessarily because they are causally connected, per se, but because they are entangled by the ways people actually live in their societal context, replete with constraints as well as possibilities". Another important aspect of the alcohol-harm paradox is how intertwined and entangled such risk factors can be within a person's social and physical environment. An example stems from alcohol outlet density. It has been shown that increases in alcohol availability locally (especially via on-premise density) is associated with increases not only in consumption, but also in alcohol-related harm.7Livingston M Chikritzhs T Room R Changing the density of alcohol outlets to reduce alcohol-related problems.Drug Alcohol Rev. 2007; 26: 557-566Crossref PubMed Scopus (203) Google Scholar Furthermore, alcohol outlet density and alcohol harm correlate positively with neighbourhood deprivation.8Romley JA Cohen D Ringel J Sturm R Alcohol and environmental justice: the density of liquor stores and bars in urban neighborhoods in the United States.J Stud Alcohol Drugs. 2007; 68: 48-55Crossref PubMed Scopus (154) Google Scholar, 9Berke EM Tanski SE Demidenko E Alford-Teaster J Shi X Sargent JD Alcohol retail density and demographic predictors of health disparities: a geographic analysis.Am J Public Health. 2010; 100: 1967-1971Crossref PubMed Scopus (84) Google Scholar A deeper understanding of the potentially complex mechanisms behind the paradox should be the next challenge for alcohol epidemiology and public health research in general. Future research might show that the approaches that public health practitioners need to take to tackle the uneven health burden of alcohol use are the same as those used to address the breadth of public health challenges—that is, they should be rooted in an environmental and eco-social understanding of health. I declare no competing interests. The role of alcohol use and drinking patterns in socioeconomic inequalities in mortality: a systematic reviewTo reduce socioeconomic inequalities in mortality, addressing heavy episodic drinking in particular, rather than alcohol use in general, is worth exploring as a public health strategy. Full-Text PDF Open AccessFailing to address the burden of alcoholExcessive alcohol consumption is a leading cause of disease and premature mortality worldwide. Harmful alcohol use costs 3 million lives a year globally, is the seventh most important risk factor for mortality overall, and the number one risk factor for people aged 15–49 years. Excessive alcohol consumption increases the risk of a wide range of diseases, including cardiovascular diseases, liver disease, and cancers, and it can severely impact mental health and become a source of addiction. Despite the evident harms, it remains a major public health issue. Full-Text PDF Open Access