Y Radif. Introduction

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1 Why do poor people have more alcohol-related deaths than rich people? Discuss whether it is true that higher socioeconomic class is associated with higher alcohol intake but with less alcohol-related health harm than lower socioeconomic class, and the possible reasons for this. Introduction The relationship between socioeconomic status (SES) and the effects of alcohol consumption is a controversial issue that is more complex than initially meets the eye. Numerous studies have shown that those of a lower SES, although consuming less alcohol than those of a high SES, seem to suffer from more alcohol-related health harm, and ultimately, a higher mortality rate. This essay aims to establish whether this is indeed true, and to explore the underlying reasons behind this supposed correlation. In order to do so, it is first important to understand the concept of SES, and the different ways in which it can be defined. Subsequently, it is essential to examine alcohol consumption across the socioeconomic gradient. Rather than relying on volume alone, the topic will be discussed from a multi-dimensional perspective, to address various aspects of alcohol consumption, such as drinking patterns, environmental context, and the different levels at which the problem may lie. Finally, the data itself will be appraised to determine whether it accurately represents the problem at hand. The disparity in alcohol-related health harm across the socioeconomic gradient is ultimately a puzzling concept, and may rely on many interacting factors. By dissecting these factors and their potential consequences, it may become possible to answer the question of why the poor suffer from more alcohol-related health harm despite drinking less than their richer counterparts. How Do We Measure Socioeconomic Status (SES)? The classic definition of SES refers to an individual s or group s position within a hierarchical social structure. SES is based upon factors such as stability of income, occupation, education, and power, and can be categorised into low, moderate and high. 1 However, in reality, these factors are interlinked, and it is difficult to organise individuals into specific groups. Ultimately, financial stability is the underlying factor of SES; being financially less privileged causes individuals to be at a significant disadvantage within society. Perhaps most relevant to this topic, are the discrepancies in health and well-being amongst the different social classes. SES has been described as the most powerful predictor of disease, disorder, injury and mortality. 2 Indeed, existing in a state of poverty has become a predictor for a poorer quality of life and a lower life expectancy. Those of a low SES have been shown to have significantly higher rates of mental and physical illness, such as anxiety, depression and cardiovascular disease. 3 1

2 The Alcohol Harm Paradox A lower SES is associated with higher acute and chronic alcohol-related disease compared to a higher SES. These diseases include hypertension, liver disease, head and neck cancers, and alcohol dependency, as well as alcohol-related mortality. 4 A 2014 report on alcohol-related health inequality in England and Wales found that the most socioeconomically deprived 20% of the population accounted for 29% of alcohol-related deaths, whereas the least deprived of the population accounted for just 12%. 5 Figure 1 shows alcohol-specific and alcohol-related mortality according to deprivation quintile. Despite this, it has been shown that those of a low SES drink less than their more privileged Figure 1: There is a negative correlation between alcohol specific mortality and death and socioeconomic status. However, percentage of risk drinkers decreases with deprivation quintile. 6 counterparts. A comparative international study of alcohol consumption showed that higher SES and higher education levels are positively correlated with drinking status. 7 Additionally, lower income groups have been found to be more likely to abstain from alcohol. 8 (See Figure 2) 2

3 Figure 2: Consumption patterns of alcohol in males and females according to social class. 8 Herein lies the so-called alcohol harm paradox 6 ; despite seemingly drinking less alcohol, those of a lower social class carry the burden of alcohol-related health harm, more so than those of a higher social class. This essay aims to approach the question as to why the poor suffer greater alcohol-related health harm than the rich, despite the apparent discrepancy in alcohol consumption. Whilst many studies have used sheer volume of alcohol consumption as a measure of alcoholrelated health harm, 9 the alcohol-harm paradox is complicated and multifaceted. In order to fully understand the question, it is therefore vital to examine the different dimensions of drinking. That is to say, the problem does not rely solely on amounts of alcohol consumed, but a whole host of factors that are often interlinked. By examining these factors, it might then become possible to solve the paradox that has persisted throughout time. 3

4 The Dimensions of Drinking Relying upon volume of alcohol consumption alone would be a very one-dimensional approach to addressing why the poor suffer from greater alcohol-related health harm. Instead, this report aims to glean a broader perspective, by addressing all angles of alcohol consumption. This includes not only sheer amounts, but alcohol quality, patterns and frequency of drinking, as well as the social context in which alcohol is consumed. Motives for Drinking Alcohol Perhaps the most basic question to ask is why the rich and poor choose to drink alcohol, despite drinking different amounts. It can be said that as a generalisation, the rich man is very much enveloped in the culture of drinking. Alcohol is a social tool, used for enjoyment and pleasure. The culture of drinking is especially prevalent amongst young professionals in urban settings, who are often found to grab a drink after work. 10 Contrasted with this are the poor, who carry the social stereotype of drinking to escape the woes of their lives. 11 For the poor, drinking is not a pastime, but a distraction. They might use alcohol to self-medicate 12 and alleviate the suffering of their lives. That is not to say that the rich do not drink as a distraction, but that they are less likely to encounter stress, and do not have to contend with the additional emotional and financial pressures that are imposed upon the poor. 13 (See Figure 3) Figure 3: Illustration of the discrepancies in stress level, as well as other emotions, according to income. Those defined as poor suffer higher rates of these emotions. 14 4

5 However, the question remains as to why the rich drink more, despite seemingly facing less financial and emotional stress. The simple answer to this question may be because rich people can afford to drink more than poor people. Additionally, the rich are more likely to engage in social activities where alcohol would be present, such as parties or work events. The rich can afford to attend these events, and therefore they can afford to drink at them. Such environments often become a competition to demonstrate financial worth; for the rich, alcohol is merely a social supplement and necessary enjoyment. 15 Because the poor are more likely to drink due to stress, as opposed to enjoyment, 16 the effects of their drinking may be more severe, even if they drink less than their richer counterparts. According to the stress reduction hypothesis, stress-related drug use may ultimately contribute to abuse and dependency. 12 Motive might therefore be an important foundation in determining the short and long-term effects of drinking alcohol across different socio-economic groups. This information on its own, however, is not sufficient to answer the question as to why the rich drink more, but suffer fewer health-related consequences. This will be further explored in the following sections. Frequency and Patterns It has been found that SES shapes the patterns and frequency of drug use, and that alcoholrelated health consequences may be associated with the way in which people consume alcohol. For example, it has been found that those of a low SES are more likely to binge drink 17 (defined as consuming a large amount of alcohol in a short amount of time 18 ). On the other hand, those of a high SES tend to have more drinking occasions but these are more likely to be of light-to-moderate consumption. 4 A study carried out during the 2008 England recession observed less hazardous drinking amongst the general population, but increases in binge-drinking amongst those who were unemployed. 19 Therefore, although the rich may drink more in terms of volume, the way this is distributed differs greatly. Rich people tend to drink moderate amounts spread throughout the week, whereas those of a lower SES are found to have an all or nothing approach to drinking; either abstaining completely or drinking to excess (see Figure 2). There is a distinct difference between alcohol dependency and alcohol abuse. Although the poor might be less likely to have access to alcohol, they are more likely to suffer from alcohol dependency, which is associated with heavy alcohol consumption as well as chronic psychological and physical illness. 20 On the other hand, rates of alcohol abuse, which is seen a less severe alcohol disorder, are higher in those of a higher SES 21, as seen in Figures 4 and 5. This presents another dimension; whilst the rich might drink more often, the poor show a greater reliance upon alcohol, which follows them throughout the course of their lives. 22 5

6 Figure 4: There is a positive correlation between alcohol abuse and education level, and a negative correlation between alcohol dependency and education level. 21 Figure 5: There is a positive correlation between alcohol abuse and income, and a negative correlation between alcohol dependence and income. 21 6

7 Based on this, it may be misleading to claim that the rich drink more alcohol than the poor; it might be more appropriate to say that more rich people than poor people drink alcohol, but that they drink to a different degree. Ultimately, it appears that although the rich are more exposed to alcohol, they are able to control the way they drink, whereas the poor are not afforded this luxury. This discrepancy may be directly related to both the psychosocial and environmental context in which alcohol consumption takes place, which will be discussed in the following section. Environmental and Psychosocial Context As aforementioned, affluent people tend to drink in social environments, for instance, workrelated events, or amongst friends. 10 For the rich, drinking, even to excess, is glamourous. However, although they may drink hazardous amounts of alcohol in these situations, existing in a high SES provides a buffer that insulates them from the negative consequences of their actions. 4 The rich may have stronger social support networks, and so are better able to control their drinking. Additionally, the responsibilities of work and social constraints such as taking care of a family suggest that the rich are grounded by the routine and stability of their lives. For those of a low SES, drinking alcohol may also be social, but this will take place in unsafe settings, 4 often frequented by other high risk drinkers. This might expose individuals to violence and unintentional injury, and in the long term, infectious diseases such as HIV. 23 It has been found that despite having identical drinking patterns, those that consume alcohol in heavy drinking environments suffer more alcohol-related harm. 9 However, it has also been found that the poor are more likely to drink at home. 24 Factors such as unemployment are compounded with psychosocial distress, such as depression or anxiety, causing individuals to spiral into isolation and turn to alcohol for solace. 25 Unable to afford goodquality alcohol, these people may binge on low-quality drinks that could contribute to more severe future health consequences. 24 Another important factor to consider is the general living environment across the SES gradient. It may not be low SES itself that dictates greater alcohol-related health harm, but where it places individuals within society. Neighbourhood disadvantage has been shown to correlate with increased psychological distress, 26 causing individuals to binge-drink as a form of self-medication. 27 Growing up in a disadvantaged neighbourhood also means that there is exposure to alcohol from a young age; such areas tend to have values that tolerate alcoholism. 26 On the contrary, the rich see alcoholism as something to be frowned upon, further adding to the fact that poorer people are more likely to suffer from alcohol dependency, and as a consequence, alcohol-related disease. Neighbourhood status is therefore a key factor in shaping alcohol consumption patterns, and ultimately, alcoholrelated health harm. Associated Risk Factors Lower SES has been found to be associated with a higher body mass index, higher rates of cardiovascular disease, 3 and higher rates stress and depression. 12 Poorer people also have less access to healthier foods, resulting in nutritional deficiencies. 2 The principle of 7

8 cumulative disadvantage suggests that those of a lower SES are more vulnerable to alcohol-related problems due to other poor lifestyle factors. For instance, nutritional deficiencies weaken the immune system, and therefore negatively impact recovery from alcohol-related illnesses. 4 This clustering 6 of pre-existing unhealthy behaviours means that the effects of alcohol are amplified in deprived areas, causing poorer people to suffer from greater alcohol-related health harm, despite drinking the same or less than their richer counterparts. On the other hand, those of a higher SES, perhaps due to higher education levels, are more aware of the consequences of their behaviour and therefore more prone to make healthier choices. 28 In fact, healthy eating and exercising has become part of the wealthy lifestyle; in the age of costly superfoods and green juices that only the rich can afford, 29 it is no wonder that they are physically healthier, and therefore suffer less from the ill effects of excessive alcohol consumption. Access to Treatment Despite the age-old saying that prevention is better than cure, it is apparent that the poor do not have the means to prevent alcohol-related health harm. However, nor are they able to cure it. People of a low SES are more susceptible to the harmful effects of alcohol, partly due to the disparity in access to health services, treatments, and rehabilitation. 6 Public health services have long waiting lists for treatment, and poorer people are less likely to adhere to treatments or attend follow-up appointments. 30 For those who are alcoholdependent, it can be difficult to find rehabilitation or detoxification centres, which exacerbates the effects of chronic illness. 25 Furthermore, poorer people might not be able to attend appointments for treatment, due to family responsibilities, and lack of availability of care for their children. In several studies carried out in Australia, the United Kingdom and the United States, it was found that the general public believed that those who were alcohol-dependent should be less prioritised in health care settings. 31 Seeing as poorer people are more likely to be alcohol dependent, 20 it is no surprise that they carry the burden of alcohol-related health harm. In relation to this, in the United States, many insurance companies will not cover alcohol-related conditions. Additionally, in some developing countries, shortages in health care services for chronic illnesses has meant that alcohol-related diseases often go untreated, where they may become unnecessarily fatal. 4 This would pose little problem for those of a high SES, who have the means and the time to seek out treatment, for both alcohol dependence and for alcohol-related illnesses. Those who can afford private alcohol treatment centres find themselves being treated much more quickly. 25 As aforementioned, the rich are generally more aware of the consequences of their behaviour. 28 They might therefore be more proactive in seeking treatment for illnesses, as well as being more likely to comply with treatment and follow-up. 30 Ultimately, this means that the poor are more likely to suffer from alcohol-related health harm, because they are less able to access treatment, even when it is available to them. 8

9 Cause and Effect Thus far, the idea that low SES causes increased alcohol-related health harm has been explored extensively. However, the converse may also be true. High rates of alcohol use have been found to contribute to increased levels of neighbourhood disadvantage; many who consume alcohol excessively have found themselves unemployed as a result. 16 Similarly, those who suffer from chronic disease caused by alcohol are unable to work; this may even hold true for those of a high SES who descend into alcoholism. 25 This cycle of poverty and substance abuse becomes impossible to break and individuals may find themselves falling further into a deprived state. Those who suffer from alcohol-related health harm may well migrate to disadvantaged neighbourhoods, 16 and become unable to improve their situation. Therefore, not only does SES affect alcohol-related health harm, but suffering from alcohol dependency and alcohol-related illness can also cause socio-economic deprivation. This shows the complexity of the factors that contribute to alcohol-related disease; not only are they interlinked, they are exacerbated by each other, so much so that it becomes difficult to separate cause from effect. Misinformation Having discussed the findings of studies that have investigated the disparity in alcoholrelated health harm, it is important to critically assess whether they truly represent the problem at hand. Firstly, much of available data presents alcohol prevalence rather than patterns or distribution of consumption. As mentioned, relying solely on sheer volume of alcohol consumption as a measure of intake is a rather unreliable way of determining the effects of alcohol upon health. What is more, much of the data were obtained from selfreport, 32 which would be subject to recall bias, potentially underestimating or overestimating the volume of alcohol consumption across the SES gradient. It has also been found that clinical population studies are selectively biased towards people of a low SES, leading to their overrepresentation in the data. 25 On the other hand, other studies were found to be more likely to include those in higher income groups, based on their diagnostic criteria. 33 Most of these studies are cross-sectional, 20 which means that they fail to observe changes over time. For instance, taking a sample of a working population would fail to represent the heaviest drinkers who might have become unemployed as a consequence of their drinking. SES is fluid, and although many will remain in the same SES throughout their lives, alcohol abuse and dependence is a factor than can cause even high earners to fall into a state of deprivation through drinking. Finally, the parameters of defining SES and alcohol consumption are not standardised; different indicators can lead to different results. It therefore becomes difficult to disentangle the various factors, and as a result, the overall picture of alcohol-related health harm according to SES may not fully reflect the true and current situation. 9

10 Conclusion Superficially, there is a clear disparity in the amount of alcohol consumed across the socioeconomic gradient, which is not reflected in the observed rates of alcohol-related health harm. Alcohol consumption is complex and so are its consequences; this discrepancy is therefore likely to be due to numerous factors, some of which have been discussed. Pattern, frequency and environment of drinking are likely to influence alcohol-related disease to a greater degree than alcohol volume itself. Additionally, the problem is likely to exist at all levels, such as pre-existing health problems, and a lack of access to healthcare in those of a lower SES. Finally, the data, although vast, is in parts incomplete, and does not always represent the situation accurately. Although this essay has examined these factors in detail, the answer as to why the poor suffer from greater alcohol related deaths is not yet clear, and perhaps will not be for quite some time. It is important to understand the complexities of alcohol consumption, abuse and dependence, and how they are affected by SES. None of the elements exist in isolation, and they waver with the passing of time. If we are to fully solve the problem, we must start at the beginning; that is, by reducing the ever-widening gap between the rich and the poor. Only when this is achieved, will it be possible to understand and eliminate the disparity in alcohol-related health harm across the socio-economic gradient. References 1. Socioeconomic Status Education.com [Internet]. Education.com [cited 20 March 2016]. Available from: 2. Conway C. Poor Health: When Poverty Becomes Disease [Internet]. UC San Francisco [cited 20 March 2016]. Available from: 3. Newacheck P, Hung Y, Jane Park M, Brindis C, Irwin C. Disparities in Adolescent Health and Health Care: Does Socioeconomic Status Matter?. Health Serv Res. 2003;38(5): Blas E, Kurup A. Equity, social determinants and public health programmes. Switzerland: World Health Organization; Erskine S, Maheswaran R, Pearson T, Gleeson D. Socioeconomic deprivation, urban-rural location and alcohol-related mortality in England and Wales. BMC Public Health. 2010;10(1): Alcohol Research UK. Understanding the alcohol harm paradox in order to focus the development of interventions [Internet]. Liverpool: Centre for Public Health, Faculty of Education, Health & Community, Liverpool John Moores University; 2015 p Available from: 7. Grittner U, Kuntsche S, Gmel G, Bloomfield K. Alcohol consumption and social inequality 10

11 at the individual and country levels--results from an international study. The European Journal of Public Health. 2012;23(2): Knupfer G. The Prevalence in Various Social Groups of Eight Different Drinking Patterns, from Abstaining to Frequent Drunkenness: analysis of 10 U.S. surveys combined. Addiction. 1989;84(11): Rehm J. SCHOOL MATTERS: DRINKING DIMENSIONS AND THEIR EFFECTS ON ALCOHOL- RELATED PROBLEMS AMONG ONTARIO SECONDARY SCHOOL STUDENTS. Alcohol and Alcoholism. 2005;40(6): Crum R, Helzer J, Anthony J. Level of education and alcohol abuse and dependence in adulthood: a further inquiry. Am J Public Health. 1993;83(6): Barber N. Are Rich People Heavy Drinkers? [Internet]. Psychology Today [cited 17 March 2016]. Available from: Boardman J, Finch B, Ellison C, Williams D, Jackson J. Neighborhood Disadvantage, Stress, and Drug Use among Adults. Journal of Health and Social Behavior. 2001;42(2): FORUT. Alcohol and Poverty: Some Connections [Internet]. FORUT; 2016 p Available from: Graham C. The high costs of being poor in America: Stress, pain, and worry [Internet]. The Brookings Institution [cited 20 March 2016]. Available from: Drum K. The Rich Drink Differently From You and Me [Internet]. Mother Jones [cited 20 March 2016]. Available from: Rhodes J, Jason L. A social stress model of substance abuse. Journal of Consulting and Clinical Psychology. 1990;58(4): World Health Organisation. Alcohol and inequities [Internet]. Copenhagen: WHO; 2014 p Available from: data/assets/pdf_file/0003/247629/alcohol-and- Inequities.pdf 18. Binge drinking - Live Well - NHS Choices [Internet]. Nhs.uk [cited 21 March 2016]. Available from: Harhay M, Bor J, Basu S, McKee M, Mindell J, Shelton N et al. Differential impact of the economic recession on alcohol use among white British adults, The European Journal of Public Health. 2013;24(3): Keyes K, Hasin D. Socio-economic status and problem alcohol use: the positive 11

12 relationship between income and the DSM-IV alcohol abuse diagnosis. Addiction. 2008;103(7): Hasin D, Stinson F, Ogburn E, Grant B. Prevalence, Correlates, Disability, and Comorbidity of DSM-IV Alcohol Abuse and Dependence in the United States. Arch Gen Psychiatry. 2007;64(7): Harrison L, Gardiner E. Do the rich really die young? Alcohol-related mortality and social class in Great Britain, Addiction. 1999;94(12): Wiley J, Weisner C. Drinking in violent and nonviolent events leading to arrest: Evidence from a survey of arrestees. Journal of Criminal Justice. 1995;23(5): Morrissey J. In Recession, Drinking Moves from Bars to Home [Internet]. TIME.com [cited 22 March 2016]. Available from: How to Know When to Seek Treatment for Alcoholism [Internet]. Alcohol Rehab. [cited 20 March 2016]. Available from: Aneshensel C, Sucoff C. The Neighborhood Context of Adolescent Mental Health. Journal of Health and Social Behavior. 1996;37(4): Cerda M, Diez-Roux A, Tchetgen Tchetgen E, Gordon-Larsen P, Kiefe C. The Relationship Between Neighborhood Poverty and Alcohol Use: Estimation by Marginal Structural Models. Epidemiology. 2010;21(4): Van Oers J. Alcohol consumption, alcohol-related problems, problem drinking, and socioeconomic status. Alcohol and Alcoholism. 1999;34(1): Philpott T. The rich are eating richer, the poor are eating poorer [Internet]. Mother Jones [cited 21 March 2016]. Available from: Jin J, Li S. PMC9 A REVIEW OF FACTORS AFFECTING THERAPEUTIC COMPLIANCE. Value in Health. 2006;9(6):A272-A Cartwright A, Shaw S, Spratley T. The Relationships between per capita Consumption, Drinking Patterns and Alcohol Related Problems in a Population Sample, Part I: Increased Consumption and Changes in Drinking Patterns. Addiction. 1978;73(3): Dawson D. Methodological Issues in Measuring Alcohol Use. Alcohol Research and Health. 2003;27(1): Marmot M. Inequality, deprivation and alcohol use. Addiction. 1997;92(3):