Deconstructing the Alcohol Harm Paradox: A Population Based Survey of Adults in England.
BACKGROUND
The Alcohol Harm Paradox refers to observations that lower socioeconomic status (SES) groups consume less alcohol but experience more alcohol-related problems. However, SES is a complex concept and its observed relationship to social problems often depends on how it is measured and the demographic groups studied. Thus this study assessed socioeconomic patterning of alcohol consumption and related harm using multiple measures of SES and examined moderation of this patterning by gender and age.


METHODS
Data were used from the Alcohol Toolkit Study between March and September 2015 on 31,878 adults (16+) living in England. Participants completed the AUDIT which includes alcohol consumption, harm and dependence modules. SES was measured via qualifications, employment, home and car ownership, income and social-grade, plus a composite of these measures. The composite score was coded such that higher scores reflected greater social-disadvantage.


RESULTS
We observed the Alcohol Harm Paradox for the composite SES measure, with a linear negative relationship between SES and AUDIT-Consumption scores (β = -0.036, p<0.001) and a positive relationship between lower SES and AUDIT-Harm (β = 0.022, p<0.001) and AUDIT-Dependence (β = 0.024, p<0.001) scores. Individual measures of SES displayed different, and non-linear, relationships with AUDIT modules. For example, social-grade and income had a u-shaped relationship with AUDIT-Consumption scores while education had an inverse u-shaped relationship. Almost all measures displayed an exponential relationship with AUDIT-Dependence and AUDIT-Harm scores. We identified moderating effects from age and gender, with AUDIT-Dependence scores increasing more steeply with lower SES in men and both AUDIT-Harm and AUDIT-Dependence scores increasing more steeply with lower SES in younger age groups.


CONCLUSIONS
Different SES measures appear to influence whether the Alcohol Harm Paradox is observed as a linear trend across SES groups or a phenomenon associated particularly with the most disadvantaged. The paradox also appears more concentrated in men and younger age groups.
Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom.|Department of Epidemiology and Public Health, University College London, London, United Kingdom.
Emma
E
Beard
Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom.|Department of Epidemiology and Public Health, University College London, London, United Kingdom.
Jamie
J
Brown
Department of Epidemiology and Public Health, University College London, London, United Kingdom.
Robert
R
West
ScHARR, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom.
Colin
C
Angus
ScHARR, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom.
Alan
A
Brennan
ScHARR, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom.
John
J
Holmes
Institute of Health & Society, Newcastle University, Newcastle, United Kingdom.
Eileen
E
Kaner
ScHARR, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom.
Petra
P
Meier
Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom.
Susan
S
Michie
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