Socioeconomic differences in alcohol use, disorders and harm : Exploring the Alcohol Harm Paradox

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http://urn.fi/URN:ISBN:978-951-51-6920-4
Title: Socioeconomic differences in alcohol use, disorders and harm : Exploring the Alcohol Harm Paradox
Author: Peña, Sebastián
Contributor: University of Helsinki, Faculty of Medicine, Clinicum
Doctoral Program in Population Health
Finnish Institute for Health and Welfare, Department of Public Health Solutions
Publisher: Helsingin yliopisto
Date: 2021-01-22
Language: en
Belongs to series: Dissertationes Scholae Doctoralis Ad Sanitatem Investigandam Universitatis Helsinkiensis - URN:ISSN:2342-317X
URI: http://urn.fi/URN:ISBN:978-951-51-6920-4
http://hdl.handle.net/10138/323980
Thesis level: Doctoral dissertation (article-based)
Abstract: Harmful alcohol use is a global public health challenge. Socioeconomic differences in alcohol-attributable harm are higher than in all-cause mortality and Finland has one of the highest socioeconomic differences in alcohol-attributable harm in European countries. Lower socioeconomic groups typically experience greater alcohol-attributable harm, despite reporting lower levels of alcohol use. This “alcohol harm paradox” can be the result of differential biases in the measurement of alcohol use, differential vulnerability to the effects of alcohol or reverse causality. What explains the alcohol harm paradox remains largely unknown. This study investigated the existence and patterns of socioeconomic differences in volume of alcohol use and drinking patterns in Finland and Chile (two countries with high alcohol use and harm); examined changes in the prevalence and socioeconomic correlates of alcohol use disorders (AUD) in Finland between 2000 and 2011; and examined whether differential biases in the measurement of volume of alcohol use (using alcohol biomarkers as objective measures of alcohol use) and behavioural risk factors and their joint effects with each other and with socioeconomic status (SES) could explain the alcohol harm paradox. We used data from national health surveys in Finland and also Chile in Sub-study I. The study population were adults residing permanently in Finland. Income and education were used as indicators of SES. Central measurements included alcohol use (volume and heavy episodic drinking), alcohol biomarkers (GGT, CDT, ALT and AST), smoking, body mass index as well as sociodemographic factors. We used structured interviews to assess 12-month and lifetime AUD and linked data from population surveys to mortality data. Outcomes were indicators of alcohol use, 12-month and lifetime prevalence of AUD and alcohol-attributable mortality. Statistical methods included the concentration index, logistic and Cox proportional hazards models and causal mediation analysis. Abstinence was higher among lower socioeconomic groups than in higher socioeconomic groups in Finland and Chile, while heavy episodic drinking was modestly higher among people with lower SES in Finland. Estimated prevalence of 12-month AUD in Finland decreased from 4.6% in 2000 to 2.0% in 2011. We did not find evidence to support the existence of educational differences in AUD in 2000 or 2011. Participants in the lowest income quintile experienced 2.1 times higher risk of alcohol-attributable mortality, despite reporting lower levels of alcohol use. Alcohol biomarkers explained a very small fraction of the socioeconomic differences in alcohol-attributable mortality. We found strong joint (or interactive) effects for SES and alcohol use and SES and smoking. However, smoking, body mass index and their joint effects with income explained a relatively small proportion (18%) of the effect of income on alcohol-attributable mortality. Our findings confirm the existence of the alcohol harm paradox in Finland and support the need for targeted alcohol policies for lower socioeconomic groups and a broader policy agenda for tackling structural determinants of health.Harmful alcohol use is a global public health challenge. The differences between socioeconomic groups in the harm caused by alcohol are higher than in mortality for any cause. Finland has one of the highest socioeconomic differences in the harm caused by alcohol in European countries. People in lower socioeconomic groups typically experience greater harm caused by alcohol, despite reporting lower levels of alcohol use. This “alcohol harm paradox” can be the result of differences in how socioeconomic groups report their alcohol use, higher vulnerability to the effects of alcohol or reverse causality. What explains the alcohol harm paradox remains largely unknown. This study investigated the socioeconomic differences in the volume of alcohol use (amount of alcohol drank) and drinking patterns (how was alcohol drank) in Finland and Chile (two countries with high alcohol use and harm); examined changes in the proportion of people with alcohol use disorders (AUD) in Finland between 2000 and 2011 and changes in these proportion in different socioeconomic groups; examined whether people from different socioeconomic groups reported differently their alcohol use (using biological markers of alcohol use as objective measures of alcohol use) and examined whether the behavioural risk factors and their joint effects with each other and with socioeconomic status (SES) could explain the alcohol harm paradox. We used data from national health surveys in Finland and also Chile in Sub-study I. The study population were adults residing permanently in Finland. Income and education were used as indicators of SES. Central measurements included alcohol use (volume and heavy episodic drinking), alcohol biomarkers (GGT, CDT, ALT and AST), smoking, body mass index as well as sociodemographic factors. We used structured interviews to assess the proportion of people with AUD in the last 12 months and during their lifetime and linked data from population surveys to mortality data. Outcomes were indicators of alcohol use, the proportion of people with AUD in the last 12 months and during their lifetime and deaths caused by alcohol. Statistical methods included the concentration index, logistic and Cox proportional hazards models and causal mediation analysis. We found that the proportion of non-drinkers was higher in the lower socioeconomic groups than in higher socioeconomic groups in Finland and Chile, while heavy episodic drinking (drinking a high amount of alcohol on a single occasion) was modestly higher among people with lower SES in Finland. The proportion of people with AUD in the past 12 months in Finland decreased from 4.6% in 2000 to 2.0% in 2011. We did not find evidence to support the existence of educational differences in AUD in 2000 or 2011. Participants in the lowest income quintile experienced 2.1 times higher risk of death caused by alcohol, despite reporting lower levels of alcohol use. Biological markers of alcohol use explained a very small fraction of the socioeconomic differences in deaths caused by alcohol. We found strong joint effects (or interactive) for SES and alcohol use and SES and smoking. However, smoking, body mass index and their joint effects with income explained a relatively small proportion (18%) of the effect of income on deaths caused by alcohol. Our findings confirm the existence of the alcohol harm paradox in Finland and support the need for alcohol policies designed specifically for lower socioeconomic groups and a broader policy agenda for tackling structural conditions that affect health.
Subject: public Health
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