Income inequality, alcohol use, and alcohol-related problems

Community characteristics and substance-free activity and service access predict membership in alcohol use disorder risk profiles

OBJECTIVE

Community characteristics (e.g., alcohol access, poverty) are associated with alcohol use disorder (AUD) at the population level, and person-level AUD severity indicators (e.g., drinking practices, problems) predict heterogeneity in individual AUD risk profiles and recovery outcomes. Guided by behavioral economic theory, this study investigated whether residing in relatively enriched communities with substance-free reward sources, greater health/behavioral health care access, lower alcohol access, and less poverty were associated with less risky individual AUD risk profiles.

METHOD

This secondary analysis combined an integrated data set of individual natural recovery attempts with zip code community characteristics obtained from public data sources. Four AUD latent risk profiles, previously derived from individual problem severity indicators that predicted 1-year recovery outcomes, were predicted by zip code-level substance-free reward sources, alcohol access, health/behavioral health care access, and poverty surrounding AUD recovery (N = 528).

RESULTS

As hypothesized, multinomial regression analyses indicated that greater community access to substance-free reward sources (educational services, religious organizations, sports/fitness/recreation programs, fresh food) and lower community poverty were associated with lower AUD risk profiles compared with higher AUD risk profiles. This pattern was most pronounced in comparisons between a global lower risk profile and a higher risk profile characterized by high alcohol dependence and alcohol-related psychosocial problems. Alcohol access and health care access did not differentiate profile membership.

CONCLUSIONS

Results suggest that community characteristics contribute to heterogeneity in individual drinking problem development, and community enrichment may offer a promising approach to AUD prevention and promotion of positive recovery outcomes. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Socioeconomic disparities in mortality from indoor air pollution: A multi-country study

BACKGROUND

Indoor air pollution is a major public health concern, contributing to approximately 2.9 million deaths and 81.1 million disability-adjusted life years lost annually. This issue disproportionately affects underprivileged communities that depend on solid fuels for cooking. As a result, these communities suffer from heightened exposure to indoor air pollutants, which increases the risk of morbidity, mortality, and worsening health disparities.

OBJECTIVE

This study investigates the association between socioeconomic status and mortality related to indoor air pollution across multiple countries.

METHODS

Data from the 2019 Demographic and Health Survey, WHO, and World Bank were utilized to examine the impact of socioeconomic status on indoor air pollution-related mortality. The primary outcome was mortality associated with solid fuel use, with income quintiles as the independent variable. Linear and logistic regression analyses were applied to assess these relationships.

RESULTS

Logistic regression analysis revealed a strong negative association where household income increases and indoor air pollution-related mortality significantly decreases. Specifically, Households in the highest income quartile showed a 22% reduction progressively in the odds of mortality risk compared to the lowest income quintile. Additionally, access to clean fuel correlated with a 0.59 times lower odds of mortality, highlighting the clean energy sources' protecting effect.

CONCLUSION

The findings highlight the critical need to prioritize clean fuel access, particularly in low-income communities, to reduce indoor air pollution mortality. Policies should focus on increasing clean energy accessibility and supporting vulnerable populations through targeted subsidies and poverty alleviation programs to reduce indoor air pollution exposure disparities.

Reward deprivation is associated with elevated alcohol demand in emerging adults

Policies vary substantially in terms of providing sources of psychosocial enrichment. Behavioral economic models of substance use and addiction emphasize that deficits in access to substance-free sources of reward increase substance reinforcing value and risk for addiction. The current study used an alcohol demand curve approach to test the hypothesis that various indices of reward deprivation would be associated with elevated alcohol reinforcing efficacy. We examined associations between alcohol demand indices and several facets of reward deprivation in a sample of young adults (N = 1,331; ages 19-25 years) recruited from the United States and Canada who reported recent binge drinking. Additionally, we created an index of cumulative reward deprivation that integrated the various reward facets and examined its association with alcohol demand intensity and maximum expenditure on alcohol. Our findings indicate that reward deprivation is associated with elevated alcohol demand and provide support for alcohol prevention and intervention approaches that emphasize environmental enrichment.

IQ in high school as a predictor of midlife alcohol drinking patterns

AIMS

The aim of the present study was to assess the relationship between adolescent IQ and midlife alcohol use and to explore possible mediators of this relationship.

METHODS

Study data were from 6300 men and women who participated in the Wisconsin Longitudinal Study of high-school students graduating in 1957. IQ scores were collected during the participants' junior year of high school. In 2004, participants reported the number of alcoholic beverages consumed (past 30 days) and the number of binge-drinking episodes. A multinomial logistic regression was conducted to determine the relationship between adolescent IQ and future drinking pattern (abstainer, moderate drinker, or heavy drinker), and Poisson regression was used to examine the number of binge-drinking episodes. Two mediators-income and education-were also explored.

RESULTS

Every one-point increase in IQ score was associated with a 1.6% increase in the likelihood of reporting moderate or heavy drinking as compared to abstinence. Those with higher IQ scores also had significantly fewer binge-drinking episodes. Household income, but not education, partially mediated the relationship between IQ and drinking pattern.

CONCLUSIONS

The present study suggests that higher adolescent IQ may predict a higher likelihood of moderate or heavy drinking in midlife, but fewer binge-drinking episodes. The study also suggests that this relationship is mediated by other psychosocial factors, specifically income, prompting future exploration of mediators in subsequent studies.

The impact of the COVID-19 pandemic on the rate of primary care visits for substance use among patients in Ontario, Canada

The COVID-19 pandemic has led to an increase in the prevalence of substance use presentations. This study aims to assess the impact of the COVID-19 pandemic on the rate of primary care visits for substance use including tobacco, alcohol, and other drug use among primary care patients in Ontario, Canada. Diagnostic and service fee code data were collected from a longitudinal cohort of family medicine patients during pre-pandemic (March 14, 2019-March 13, 2020) and pandemic periods (March 14, 2020-March 13, 2021). Generalized linear models were used to compare the rate of substance-use related visits pre-pandemic and during the pandemic. The effects of demographic characteristics including age, sex, and income quintile were also assessed. Relative to the pre-pandemic period, patients were less likely to have a primary care visit during the pandemic for tobacco-use related reasons (OR = 0.288, 95% CI [0.270-0.308]), and for alcohol-use related reasons (OR = 0.851, 95% CI [0.780-0.929]). In contrast, patients were more likely to have a primary care visit for other drug-use related reasons (OR = 1.150, 95% CI [1.080-1.225]). In the face of a known increase in substance use during the COVID-19 pandemic, a decrease in substance use-related primary care visits likely represents an unmet need for this patient population. This study highlights the importance of continued research in the field of substance use, especially in periods of heightened vulnerability such as during the COVID-19 pandemic.

Inequality's on Tap: A Longitudinal Study of Area-Level Income Inequality and Alcohol Consumption Among Canadian Adolescents

PURPOSE

To determine if income inequality at the census division level is associated with alcohol consumption and abuse among junior high and high school students.

METHODS

Data on adolescents are from the Cannabis use, Obesity, Mental health, Physical activity, Alcohol use, Smoking, and Sedentary behavior (COMPASS) study. Participant data (n = 19,759) were collected during three survey waves (2016-2017, 2017-2018, and 2018-2019) and linked to 30 census divisions within four Canadian provinces. Data on income inequality and other area-level factors were derived from the 2016 Canadian census. Multilevel logistic regression modelling was used to quantify the associations between income inequality, monthly alcohol consumption, and binge drinking.

RESULTS

After adjusting for covariates, students living in census divisions within the second and third quintiles of income inequality experienced an average 80% (OR = 1.80, 95% CI = 1.08-3.02) and 92% (OR = 1.92, 95% CI = 1.05-3.51) increased odds of engaging in monthly binge drinking, respectively, compared to those living in the first quintile. Similarly, adolescents living in census divisions within the second inequality quintile experienced an average 169% (OR = 2.69, 95% CI = 1.45, 4.99) increased odds of engaging in weekly binge drinking, compared to those living in the first quintile. There was no significant association between higher income inequality and current monthly alcohol consumption.

DISCUSSION

Moderate area-level income inequality within census divisions was adversely associated with alcohol consumption among adolescents. Future work should investigate the potential mechanisms that mediate this relationship.

Relationship between characteristics of large national regions and individual alcohol consumption: a scoping review

OBJECTIVE

The goal of our article was to systematise studies that investigated the impact of living conditions in large national regions on individual alcohol consumption.

METHODS

The objectives of the scoping review, the criteria and methods for selecting articles were defined in advance and recorded in the protocol PROSPERO CRD42021234874. We sought publications on the research topic in PubMed, Google Scholar, OpenGrey, Crossref and eLibrary databases from the moment they were created until December 31, 2021. The final sample included 81 publications.

RESULTS

The majority of ultimately selected papers were published after 2010 (62 articles), represented the USA (68 articles), and considered samples of children and youths, either the younger population or the general adult population (65 articles). High quality was characteristic for 19 studies, whereas satisfactory quality was exhibited by 46 publications. The most consistent associations with individual alcohol consumption were revealed for the legislative environment (especially for integral scales and indices), alcohol pricing policy, the prevalence of alcohol consumption and binge drinking in the population, and unemployment rate.

CONCLUSION

The review made it possible to systematise the results of studies on the impact of the characteristics of large national regions on alcohol consumption, including a description of these characteristics and results, samples and designs of studies, their quality, as well as to summarise the results of these studies.

A latent class analysis of alcohol-related problems among adults who drank in the past year

Background

Research on alcohol-related problems often examines individual problem types in isolation or uses scales that provide a single cumulative severity score for alcohol-related harms. This study aims to assess the patterns of seventeen distinct alcohol-related problems and how they co-occur.

Methods

The East Bay Neighborhood Study surveyed a community sample of 864 adults who drank in the past year in Alameda County, California. Participants reported if they experienced each of seventeen alcohol-related problems in the last year. Latent class analysis assessed subgroups of problems. Logistic regression models examined associations between class membership, sociodemographics, and alcohol use.

Results

A two-class model best fit the data. The multiple problems class (18% of respondents) was characterized by experiencing problems of all types and almost all experiences of legal, violence, and risky sex-related problems. The none/few problems class (82%) was characterized by a low prevalence of all problem types, with only a small proportion experiencing hangovers. In adjusted models, only older age (AOR=0.90, 95% CI=0.88-0.92) had lower odds of multiple problems class membership.

Conclusions

Numerous alcohol-related problems co-occurred within a small subgroup of people who drank in the last year, while the majority experienced few problems. Results suggest that focusing on singular alcohol-related problems may overlook patterns of concurrent problems in high-risk groups.

Addictive behavior as molar behavioral allocation: Distinguishing efficient and final causes in translational research and practice

OBJECTIVE

Translational research on addictive behaviors viewed as molar behavioral allocation is critically reviewed. This work relates rates of behavior to rates of reinforcement over time and has been fruitfully applied to addictive behaviors, which involve excessive allocation to short-term rewards with longer term costs.

METHOD

Narrative critical review.

RESULTS

This approach distinguishes between final and efficient causes of discrete behaviors. The former refers to temporally extended behavior patterns into which the act fits. The latter refers to environmental stimuli or internal psychological mechanisms immediately preceding the act. Final causes are most clear when addictive behaviors are studied over time as a function of changing environmental circumstances. Discrete acts of addictive behavior are part of an extended/molar behavior pattern when immediate constraints on engagement are low and few rewarding alternatives are available. Research framed by efficient causes often use behavioral economic simulation tasks as individual difference variables that precede discrete acts. Such measures show higher demand for addictive commodities and steeper discounting in various risk groups, but whether they predict molar addictive behavior patterning is understudied.

CONCLUSIONS

Although efficient cause analysis has dominated translational research, research supports viewing addictive behavior as molar behavioral allocation. Increasing concern with rate variables underpinning final cause analysis and considering how study methods and temporal units of analysis inform an efficient or final cause analysis may advance understanding of addictive behaviors that occur over time in dynamic environmental contexts. This approach provides linkages between behavioral science and disciplines that study social determinants of health. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Matching, behavioral economics, and teleological behaviorism: Final cause analysis of substance use and health behavior

Howard Rachlin and his contemporaries pioneered basic behavioral science innovations that have been usefully applied to advance understanding of human substance use disorder and related health behaviors. We briefly summarize the innovations of molar behaviorism (the matching law), behavioral economics, and teleological behaviorism. Behavioral economics and teleological behaviorism's focus on final causes are especially illuminating for these applied fields. Translational and applied research are summarized for laboratory studies of temporal discounting and economic demand, cohort studies of alcohol and other drug use in the natural environment, and experimental behavioral economic modeling of health behavior-related public health policies. We argue that the teleological behavioral perspective on health behavior is conducive to and merges seamlessly with the contemporary socioecological model of health behavior, which broadens the contextual influences (e.g., community, economic, infrastructure, health care access and policy) of individuals' substance use and other health risk behaviors. Basic-to-applied translations to date have been successful and bode well for continued applications of basic science areas pioneered by Howard Rachlin and his contemporaries.

Neighborhood Disadvantage and Mental Health: Test of a Parallel Mediation Model through Social Support and Negative Emotionality

According to the life stress model, stressful circumstances occur in the context of social, psychological, and environmental features that can function as either resources or aggravating factors, each of which are associated with well-being. This research was designed to test indirect effects of living in disadvantaged neighborhoods on mental health, through reduced social support and increased negative emotionality. This model was tested with data from a national sample of 1050 adults residing in the United States. Participants completed measures of social support, negative emotionality, depression, loneliness, stress, and alcohol consumption. These scores were merged with data from the 2015 American Community Survey to assess indicators of neighborhood disadvantage at the zip code level. The test of a parallel mediation model with structural equation modeling indicated that neighborhood disadvantage did not have direct effects on either psychological distress or alcohol consumption. However, neighborhood disadvantage was associated with greater negative emotionality, and through negative emotionality, exhibited indirect effects on psychological distress and alcohol consumption. These results are consistent with elements of the life stress model that specify various psychosocial traits as maladaptive in the context of stressful environments.

Determinants of public health and interventions to address HIV infection among men who have sex with men in Miami-Dade County, Florida, USA

Human immunodeficiency virus (HIV) among men who have sex with men (MSM) has been recognized as a public health problem in Miami-Dade County, Florida, USA. This was found to be a significant problem in our need assessment as evidenced by the HIV incidence rate of 28.4 per 100,000 population, which is higher than the average incidence reported for the state of Florida. MSM account for the mostly affected group, reaching 59% of all the new cases. A review of the HIV determinants was conducted using an ecological framework. At the individual level, sexual abuse, alcohol, and drug consumption were identified as determinants of HIV infection in this population. Family rejection was recognized as a determinant at the interpersonal level. Connection to the gay community can function as a protective factor but it can also be possible predictor of HIV infection. Among structural factors, poverty was found to be positively associated with HIV prevalence. Additionally, we highlighted the importance of sexual health education and especially pre-exposure prophylaxis (PrEP) as protective factors. By using systems thinking tools, we designed a causal loop diagram that illustrates visually the recognized determinants of public health. Finally, we presented several studies that evaluate evidence-based interventions to improve the uptake and retention in care of PrEP in MSM. We also described existing interventions implemented in Miami-Dade County, and reported studies that may contribute to the development of new HIV preventive strategies in the future.

Patterns of alcohol consumption in Brazilian adults

In this study, we aimed to describe the patterns of alcohol consumption in Brazilian adults by sociodemographic characteristics and states according to sex. Cross-sectional study including 87,555 adults from the 2019 Brazilian National Health Survey who responded to a questionnaire on alcohol consumption and were classified as non-drinkers (0 g/day), light (1-12.5 g/day), moderate (12.6-49.9 g/day), and heavy drinkers (≥ 50 g/day). Of the Brazilian adults, 73.5% were non-drinkers. Among the drinkers, 14.8% were light drinkers. 82.6% of heavy drinkers were men. White participants drank more than non-white participants, except black women who were 38% more likely to be moderate drinkers than white women (ROR 1.38, 95% CI 1.09 to 1.76). Unmarried were more likely to be drinkers. Women over 55 and men over 65 years old were less likely to be drinkers. Compared to participants with none or incomplete primary education, both men and women with higher educational attainment were more likely to be light and moderate drinkers. The largest consumption of alcohol was found in Sergipe and Mato Grosso for men, and Mato Grosso do Sul and Bahia for women. Our findings may be useful to inform policies for reducing alcohol consumption in Brazil.

Causal mechanisms proposed for the alcohol harm paradox-a systematic review

BACKGROUND AND AIMS

The alcohol harm paradox (AHP) posits that disadvantaged groups suffer from higher rates of alcohol-related harm compared with advantaged groups, despite reporting similar or lower levels of consumption on average. The causes of this relationship remain unclear. This study aimed to identify explanations proposed for the AHP. Secondary aims were to review the existing evidence for those explanations and investigate whether authors linked explanations to one another.

METHODS

This was a systematic review. We searched MEDLINE (1946-January 2021), EMBASE (1974-January 2021) and PsycINFO (1967-January 2021), supplemented with manual searching of grey literature. Included papers either explored the causes of the AHP or investigated the relationship between alcohol consumption, alcohol-related harm and socio-economic position. Papers were set in Organization for Economic Cooperation and Development high-income countries. Explanations extracted for analysis could be evidenced in the empirical results or suggested by researchers in their narrative. Inductive thematic analysis was applied to group explanations.

RESULTS

Seventy-nine papers met the inclusion criteria and initial coding revealed that these papers contained 41 distinct explanations for the AHP. Following inductive thematic analysis, these explanations were grouped into 16 themes within six broad domains: individual, life-style, contextual, disadvantage, upstream and artefactual. Explanations related to risk behaviours, which fitted within the life-style domain, were the most frequently proposed (n = 51) and analysed (n = 21).

CONCLUSIONS

While there are many potential explanations for the alcohol harm paradox, most research focuses on risk behaviours while other explanations lack empirical testing.

Addiction in the time of COVID-19: Longitudinal course of substance use, psychological distress, and loneliness among a transnational Tyrolean sample with substance use disorders

INTRODUCTION

Next to an increased use of alcohol, the current pandemic has been associated with increased psychological distress among the general population. Research on its effects on individuals suffering from substance use disorders (SUD) is scarce. This study aimed at expanding the existing literature on this topic with a focus on the impact of loneliness and perceived social support.

METHODS

Sixty-eight people diagnosed with SUD according to ICD-10 from the Austrian state of Tyrol and from the Italian Province of South Tyrol who had been treated in a psychiatric hospital in 2019 and one hundred and thirty-six matched reference subjects of the same regional background participated in an online survey. Sociodemographic variables and scores on the Brief Symptom Checklist, the Three-Item Loneliness Scale, and the Multidimensional Scale of Perceived Social Support were collected at baseline and 5 months thereafter. Baseline took place after the first wave, while follow-up largely coincided with the second wave of the pandemic.

RESULTS

Among both patients and the matched reference group, substance use as a means to feel better facing the pandemic rose and predicted higher levels of psychological distress. Patients were less likely to receive specific care at follow-up than at baseline and presented with a significantly higher prevalence of clinically relevant psychological distress and loneliness than the matched reference group at both assessment times. Among both groups, psychological burden remained unchanged over time. Perceived social support was generally significantly higher in the matched reference group than in patients. Loneliness and, to a lesser degree, low perceived social support predicted psychological distress.

CONCLUSION

These findings emphasize the need of preventive and educational measures regarding substance use behavior for both individuals suffering from SUD and those without mental health disorders.

Individual and Community Social Determinants of Health and Recovery from Alcohol Use Disorder Three Years following Treatment

Prior research on recovery from alcohol use disorder (AUD) has often focused on individual-level factors that promote recovery. Given systemic health inequities, it is also important to study community-level social determinants of health (SDOH) that may promote recovery from AUD. This study extended prior work examining individual profiles of recovery from AUD to assess how individual and community SDOH at the time of treatment entry were associated with recovery from AUD three years after treatment. Data were utilized from the COMBINE study (n = 664), a multisite randomized clinical trial evaluating pharmacological and behavioral treatments for AUD. Public community data sources associated with participants' study sites were used to measure community SDOH. Multilevel latent profile analyses with individual- and community-level variables as predictors of recovery profiles were estimated. Four profiles were identified based on participants' alcohol consumption and functioning. Individual SDOH variables, such as fewer years of education and lower income, and community SDOH, including lower rates of health insurance, lower income, and greater income inequality, were each associated with lower functioning profiles. The findings highlight the importance of community SDOH in AUD recovery and the value of including both individual and community SDOH variables in research on long-term recovery.

Income inequality and non-communicable disease mortality and morbidity in Brazil States: a longitudinal analysis 2002-2017

Background

Income inequality can negatively affect population health by increasing social stress and conflict, and reducing trust, public goods and healthcare access. However there is limited evidence from low and middle-income countries (LMICs) with high levels of inequality. This study investigates the association between income inequality, morbimortality and risk factors of non-communicable diseases (NCDs) in 26 Brazilian states from 2002 to 2017.

Methods

Data was acquired for men and women from the Global Health Data Exchange, the Brazilian Institute of Geography and Statistics, and the Brazilian Ministry of Health, totalling 416 state-year observations. Disability-adjusted life years (DALYs) and risk factors of NCDs were the dependent variables. Gini Index was the main independent variable. Multivariate linear panel regressions were performed, controlling for state and time fixed effects, gross domestic product per capita, population ageing, poverty and access to healthcare.

Findings

A 1% increase in the Gini Index was associated with increases in alcohol abuse (of 923•4 DALYs per 100,000 people, 95%CI 217•6 to 1629•0) and diabetes mellitus morbidity (of 893•3 DALYs per 100,000 people, 95%CI 127•7 to 1659•0), and decreases in morbidity from attention disorder (of -4•0 DALYs per 100,000 people, 95%CI -7•4 to -0•5) and autism spectrum (of -2•4 DALYs per 100,000 people, 95%CI -4•3 to -0•5). These associations were greater for men, further supported by associations with alcohol use as a risk factor.

Interpretation

This study provides evidence from a highly unequal LMIC, Brazil, of negative associations between income inequality and NCDs, and the importance of addressing wider social determinants of health.

Funding

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brazil (CAPES) - Finance Code 001 as a Brazilian CAPES scholarship to AZD and by the São Paulo Research Foundation (FAPESP), grant 2020/15944-8 to RSG.

Neighborhood Income Inequality and Alcohol Use among Adolescents in Boston, Massachusetts

OBJECTIVES

Previous research has indicated that area-level income inequality is associated with increased risk in alcohol consumption. However, few studies have been conducted among adolescents living within smaller area units, such as neighborhoods. We investigated whether neighborhood income inequality is associated with alcohol consumption among adolescents.

METHODS

We analyzed cross-sectional data from a sample of 1878 adolescents living in 38 neighborhoods participating in the 2008 Boston Youth Survey. Multilevel logistic regression modeling was used to determine the role of neighborhood income inequality and the odds for alcohol consumption and to determine if social cohesion and depressive symptoms were mediators.

RESULTS

In comparison to the first tertile of income inequality, or the most equal neighborhood, adolescent participants living in the second tertile (AOR = 1.20, 95% CI: 0.89, 1.61) and third tertile (AOR = 1.44, 95% CI: 1.06, 1.96) were more likely to have consumed alcohol in the last 30 days. Social cohesion and depressive symptoms were not observed to mediate this relationship.

CONCLUSIONS

Findings indicate that the distribution of incomes within urban areas may be related to alcohol consumption among adolescents. To prevent alcohol consumption, public health practitioners should prioritize prevention efforts for adolescents living in neighborhoods with large gaps between rich and poor.

Binge drinking among Hispanic older adults: 2015-2019

Previous research has shown that older adults (i.e., individuals 50 years or older) show a high propensity to report unhealthy alcohol habits. Much is to be gleaned regarding these relationships among Hispanic older adults. The purpose of the present study was to examine correlates to binge drinking among a national sample of Hispanic older adults. Pooled data from the 2015-2019 National Survey on Drug Use and Health were analyzed among 4,152 Hispanic individuals. Findings revealed that a sizable percentage (17.9%) of individuals reported binge drinking in the past 30 days. Of the sample, 15.1% of individuals diagnosed with diabetes reported binge drinking and high co-morbid substance use was found. Findings can address critical gaps in Hispanic health care, prevention messaging, and harm reduction.

Beyond Behaviour: How Health Inequality Theory Can Enhance Our Understanding of the 'Alcohol-Harm Paradox'

There are large socioeconomic inequalities in alcohol-related harm. The alcohol harm paradox (AHP) is the consistent finding that lower socioeconomic groups consume the same or less as higher socioeconomic groups yet experience greater rates of harm. To date, alcohol researchers have predominantly taken an individualised behavioural approach to understand the AHP. This paper calls for a new approach which draws on theories of health inequality, specifically the social determinants of health, fundamental cause theory, political economy of health and eco-social models. These theories consist of several interwoven causal mechanisms, including genetic inheritance, the role of social networks, the unequal availability of wealth and other resources, the psychosocial experience of lower socioeconomic position, and the accumulation of these experiences over time. To date, research exploring the causes of the AHP has often lacked clear theoretical underpinning. Drawing on these theoretical approaches in alcohol research would not only address this gap but would also result in a structured effort to identify the causes of the AHP. Given the present lack of clear evidence in favour of any specific theory, it is difficult to conclude whether one theory should take primacy in future research efforts. However, drawing on any of these theories would shift how we think about the causes of the paradox, from health behaviour in isolation to the wider context of complex interacting mechanisms between individuals and their environment. Meanwhile, computer simulations have the potential to test the competing theoretical perspectives, both in the abstract and empirically via synthesis of the disparate existing evidence base. Overall, making greater use of existing theoretical frameworks in alcohol epidemiology would offer novel insights into the AHP and generate knowledge of how to intervene to mitigate inequalities in alcohol-related harm.

Neighborhood characteristics and psychiatric disorders in the aftermath of mass trauma: A representative study of New York City public school 4th-12th graders after 9/11

Studies of the relationship between neighborhood characteristics and childhood/adolescent psychopathology in large samples examined one outcome only, and/or general (e.g., 'psychological distress') or aggregate (e.g., 'any anxiety disorder') measures of psychopathology. Thus, in the only representative sample of New York City public school 4th-12th graders (N = 8202) surveyed after the attacks of 9/11/2001, this study examined whether (1) indices of neighborhood Socioeconomic Status, Quality, and Safety and (2) neighborhood disadvantage (defined as multidimensional combinations of SES, Quality and Safety indicators) are associated with eight psychiatric disorders: posttraumatic stress disorder, separation anxiety disorder (SAD), agoraphobia, generalized anxiety disorder (GAD), panic disorder, major depression, conduct disorder, and alcohol use disorder (AUD). (1) The odds ratios (OR) of psychiatric disorders were between 0.55 (AUD) and 1.55 (agoraphobia), in low and intermediate-low SES neighborhoods, respectively, between 0.50 (AUD) and 2.54 (agoraphobia) in low Quality neighborhoods, and between 0.52 (agoraphobia) and 0.65 (SAD) in low Safety neighborhoods. (2) In neighborhoods characterized by high disadvantage, the OR were between 0.42 (AUD) and 1.36 (SAD). This study suggests that neighborhood factors are important social determinants of childhood/adolescent psychopathology, even in the aftermath of mass trauma. At the community level, interventions on modifiable neighborhood characteristics and targeted resources allocation to high-risk contexts could have a cost-effective broad impact on children's mental health. At the individual-level, increased knowledge of the living environment during psychiatric assessment and treatment could improve mental health outcomes; for example, specific questions about neighborhood factors could be incorporated in DSM-5's Cultural Formulation Interview.

Therapeutic Use of Acetaminophen and Light to Moderate Alcohol: Are There Early Disparate Risks for Kidney Disease?

Introduction: Acetaminophen (APAP) is the most common medication taken in the United States. Using the 2003-2004 U.S. National Health and Nutrition Examination Survey (NHANES), the authors previously explored and reported the relationship of concomitant consumption of light to moderate alcohol (LMA) and therapeutic doses of APAP to early risk of renal dysfunction among adults in the United States. Statistically significant increased odds of renal dysfunction were noted among respondents who reported use of therapeutic doses of APAP and LMA by adjusting for hypertension, diabetes, and obesity. In this study the authors explored further on of potential disparities in the above relationship in the population. The relationship was verified with the 2009 Chronic Kidney Disease-Epidemiology Collaboration creatine-based estimated Glomerular Filtration Rate (GFR). Methods: Subgroup logistic regression analyses to assess disparities based on gender, race, age, education, and income were performed for renal dysfunction measured in terms of serum creatinine (SCr) directly as well as self-report using NHANES 2003-2004 data. Results: Early stage renal dysfunction, as determined by self-reports, and SCr and GFR values may occur among those who concomitantly ingested therapeutic doses of APAP and described alcohol use when compared to those who do not. Risks were more profound among females, particularly in minority racial groups, below legal drinking age of 21, and with household income below $25K. Conclusion: Potential risks for renal dysfunction are apparent in a disparate manner resulting in possible health inequity. Further research could increase the sample size of minority groups and specifically assess for effect modifiers that NHANES does not include for assessment.

Individual and Contextual Factors Associated With Hazardous Drinking in Spain: Evidence From a National Population-Based Study

BACKGROUND

Heavy drinking (HD) and binge drinking (BD) exhibit marked differences in their relationships with contextual-level factors imbedded in geographical areas of residence. The objective is to identify sociodemographic factors, both at the individual and at the contextual level, associated with these 2 main hazardous consumption patterns.

METHODS

Cross-sectional study using data from the 2011 to 2012 National Health Survey in Spain. The sample included 21,007 individuals ≥15 years of age. HD was defined as an alcohol intake of ≥40 g/d in men and ≥24 g/d in women. BD was defined as the consumption in the previous month of ≥6 alcoholic drinks (men) or ≥5 drinks (women) within 4 to 6 hours. Individual-level variables included sociodemographic factors, urban/rural residence, smoking, and perceived social support. Contextual-level variables covered percentage of population with no schooling, unemployment rate, and hospitality industry-related economic activity, all at the census tract level. We analyzed data using multilevel logistic regression and calculated areas under the curve (AUC).

RESULTS

Being male, smoking, high-income, and low perceived social support were associated with both hazardous drinking patterns. Younger individuals were at higher risk for BD but at lower risk for HD. BD was more common among rural than urban dwellers (odds ratios [OR] = 1.35; 95% CI: 1.05 to 1.72), whereas HD was less likely in participants residing in areas with high unemployment rates (OR = 0.62; 95% CI: 0.41 to 0.93). HD was more likely in census tracts with higher levels of hospitality industry activity (OR = 1.74; 95% CI: 1.20 to 2.54). The AUC increased substantially for both HD and BD when the census tract variable was entered in the respective models (reaching 89.5 and 93.3%, respectively).

CONCLUSIONS

Except for age, both drinking patterns have similar associations with individual-level variables but disparate links to contextual-level indicators. In both cases, accounting for area of residence substantially increased the ability to discriminate between high-risk drinkers from nonhazardous alcohol consumers.

An Opportunity to END TB: Using the Sustainable Development Goals for Action on Socio-Economic Determinants of TB in High Burden Countries in WHO South-East Asia and the Western Pacific Regions

The progress towards ending tuberculosis (TB) by 2035 is less than expected in 11 high TB burden countries in the World Health Organization South-East Asia and Western Pacific regions. Along with enhancing measures aimed at achieving universal access to quality-assured diagnosis, treatment and prevention services, massive efforts are needed to mitigate the prevalence of health-related risk factors, preferably through broader actions on the determinants of the "exposure-infection-disease-adverse outcome" spectrum. The aim of this manuscript is to describe the major socio-economic determinants of TB and to discuss how there are opportunities to address these determinants in an englobing manner under the United Nations Sustainable Development Goals (SDGs) framework. The national TB programs must identify stakeholders working on the other SDGs, develop mechanisms to collaborate with them and facilitate action on social-economic determinants in high TB burden geographical areas. Research (to determine the optimal mechanisms and impact of such collaborations) must be an integral part of this effort. We call upon stakeholders involved in achieving the SDGs and End TB targets to recognize that all goals are highly interlinked, and they need to combine and complement each other's efforts to end TB and the determinants behind this disease.

Alcohol's Secondhand Harms in the United States: New Data on Prevalence and Risk Factors

OBJECTIVE

This study examined a range of indicators of alcohol's harm to others (AHTO) among U.S. adults and assessed sociodemographic and alcohol-related risk factors for AHTO.

METHOD

The data came from 8,750 adult men and women in two parallel 2015 U.S. national surveys conducted in English and Spanish. Both surveys used computer-assisted telephone interviews and two-stage, stratified, list-assisted, random samples of adults ages 18 and older.

RESULTS

One in five adults experienced at least one of ten 12-month harms because of someone else's drinking. The prevalence of specific harm types and characteristics differed by gender. Women were more likely to report harm due to drinking by a spouse/partner or family member, whereas men were more likely to report harm due to a stranger's drinking. Being female also predicted family/financial harms. Younger age increased risk for all AHTO types, except physical aggression. Being of Black/other ethnicity, being separated/widowed/divorced, and having a college education without a degree each predicted physical aggression harm. The harmed individual's own heavy drinking and having a heavy drinker in the household increased risk for all AHTO types. The risk for physical aggression due to someone else's drinking was particularly elevated for heavy drinking women.

CONCLUSIONS

Secondhand effects of alcohol in the United States are substantial and affected by sociodemographics, the harmed individual's own drinking, and the presence of a heavy drinker in the household. Broad-based and targeted public health measures that consider AHTO risk factors are needed to reduce alcohol's secondhand harms.

Substance use: Interplay between polygenic risk and neighborhood environment

BACKGROUND

Tobacco, alcohol, and cannabis use are prevalent behaviors that pose considerable health risks. Genetic vulnerability and characteristics of the neighborhood of residence form important risk factors for substance use. Possibly, these factors do not act in isolation. This study tested the interaction between neighborhood characteristics and genetic risk (gene-environment interaction, GxE) and the association between these classes of risk factors (gene-environment correlation, rGE) in substance use.

METHODS

Two polygenic scores (PGS) each (based on different discovery datasets) were created for smoking initiation, cigarettes per day, and glasses of alcohol per week based on summary statistics of different genome-wide association studies (GWAS). For cannabis initiation one PGS was created. These PGS were used to predict their respective phenotype in a large population-based sample from the Netherlands Twin Register (N = 6,567). Neighborhood characteristics as retrieved from governmental registration systems were factor analyzed and resulting measures of socioeconomic status (SES) and metropolitanism were used as predictors.

RESULTS

There were (small) main effects of neighborhood characteristics and PGS on substance use. One of the 14 tested GxE effects was significant, such that the PGS was more strongly associated with alcohol use in individuals with high SES. This was effect was only significant for one out of two PGS. There were weak indications of rGE, mainly with age and cohort covariates.

CONCLUSION

We conclude that both genetic and neighborhood-level factors are predictors for substance use. More research is needed to establish the robustness of the findings on the interplay between these factors.

Alcohol-related emergency department visits and income inequality in New York City, USA: an ecological study

OBJECTIVES

Previous research has found that greater income inequality is related to problematic alcohol use across a variety of geographical areas in the USA and New York City (NYC). Those studies used self-reported data to assess alcohol use. This study examined the relationship between within-neighborhood income inequality and alcohol-related emergency department (ED) visits.

METHODS

The study outcome was the alcohol-related ED visit rate per 10,000 persons between 2010 and 2014, using data obtained from the New York Statewide Planning and Research Cooperative System. The main predictor of interest was income inequality, measured using the Gini coefficient from the American Community Survey (2010-2014) at the public use microdata area (PUMA) level (n=55) in NYC. Variables associated with alcohol-related ED visits in bivariate analyses were considered for inclusion in a multivariable model.

RESULTS

There were 420,568 alcohol-related ED visits associated with a valid NYC address between 2010 and 2014. The overall annualized NYC alcohol-related ED visit rate was 100.7 visits per 10,000 persons. The median alcohol ED visit rate for NYC PUMAs was 88.0 visits per 10,000 persons (interquartile range [IQR], 64.5 to 133.5), and the median Gini coefficient was 0.48 (IQR, 0.45 to 0.51). In the multivariable model, a higher neighborhood Gini coefficient, a lower median age, and a lower percentage of male residents were independently associated with the alcohol-related ED visit rate.

CONCLUSIONS

This study found that higher neighborhood income inequality was associated with higher neighborhood alcohol-related ED visit rates. The precise mechanism of this relationship is not understood, and further investigation is warranted to determine temporality and to assess whether the results are generalizable to other locales.

Psychiatric Disorders and Alcohol Consumption Among Low-Income African Americans:Gender Differences

Background: Although cooccurrence of nonsubstance use disorders (non-SUDs) and substance use is well-established in the literature, most of what we know in this regard is derived from studies that have recruited predominantly White sample populations. As a result, there is a gap in knowledge on this link among low-income African Americans (AAs). There is also a need to understand how low-income AA men and women differ in these associations. Objective: To study whether there is an association between number of non-SUDs and amount of alcohol consumption by AA adults, and whether this association varies between AA men and women. Methods: This cross-sectional study recruited a nonrandom sample of 150 AA adults with non-SUDs (i.e., major depression, bipolar disorders, obsessive–compulsive disorder, paranoid disorder, panic disorder, posttraumatic stress disorder (PTSD), and schizoaffective disorder). The independent variable was the number of non-SUDs. The dependent variable was the amount of alcohol consumption. Age, socioeconomic status (educational attainment and household income), and self-rated health were covariates. Gender was the moderator. Linear regression models were used to analyze the data. Results: A higher number of non-SUDs was not associated with a higher amount of alcohol use in the pooled sample of AA adults. We, however, found a significant interaction between gender and number of non-SUDs on the amount of alcohol use, suggesting a stronger effect of non-SUDs on alcohol consumption in AA men than in AA women. Gender-stratified linear regression models showed a positive association between number of non-SUDs and amount of alcohol consumption in AA men but not in AA women. Conclusion: Non-SUDs impact alcohol use of AA men but not women. Future research should test whether AA men may have a higher tendency to turn to alcohol to regulate their emotions and cope with psychological pain due to multiple non-SUDs. The results also suggest that integration of services for SUDs and non-SUDs may be more relevant to provision of mental health services for AA men than AA women.

Involvement in alcohol-related verbal or physical aggression. Does social status matter?

Introduction

–The analyses (1) assessed the association between social status variables and aggression when controlling for volume of alcohol consumption and episodic heavy drinking (EHD), (2) tested whether social status moderates the association between volume or EHD and verbal as well as physical aggression, and (3) investigated whether EHD moderates the effect of volume on aggression.

Methods

Swedish Alcohol Monitoring Survey (2003 to 2011); N=104,316 current drinkers; response rate: 51 to 38%. Alcohol-related aggression was defined as involvement in a quarrel or physical fight while drinking. Social status was defined as the highest education, monthly income and marital status.

Results

The associations between social status variables and aggression showed mixed results. Verbal aggression was associated with education in males and with marital status in both genders. Physical aggression was associated with education in both genders. No associations with aggression were found for income. With few exceptions, these associations remained significant when controlling for drinking patterns; social status did not moderate the association between drinking and aggression; EHD moderated the effect of volume on physical aggression in males.

Conclusions

Groups of lower educated and non-married individuals experience verbal or physical aggression over and above different levels of consumption. Individual differences in aggression vulnerability rather than differences in aggression predisposition account for higher risks of aggression in these groups.

Contextual Factors that Influence Alcohol Use Behaviors

This study tests a multilevel model of factors that affect adolescents' decisions to use alcohol. Hierarchical linear modeling was used to estimate the variance in alcohol use accounted for by the influences of individual, social, and neighborhood factors. Social factors are significant predictors of alcohol use across several models tested, while selected neighborhood factors were generally not. Results indicate that social and community contexts have important effects on adolescent alcohol use, and that social influences were more significant predictors of alcohol use than neighborhood factors for this sample.

Addressing inequities in alcohol consumption and related harms

Social determinants, or the conditions in which individuals are born, grow, live, work and age, can result in inequities in health and well-being. However, to-date little research has examined alcohol use and alcohol-related problems from an inequities and social determinants perspective. This study reviewed the evidence base regarding inequities in alcohol consumption and alcohol-related health outcomes in Australia and identified promising approaches for promoting health equity. Fair Foundations: the VicHealth framework for health equity was used as an organizing schema. The review found that social determinants can strongly influence inequities in alcohol consumption and related harms. In general, lower socioeconomic groups experience more harm than wealthier groups with the same level of alcohol consumption. While Australia has implemented numerous alcohol-related interventions and policies, most do not explicitly aim to reduce inequities, and some may inadvertently exacerbate existing inequities. Interventions with the greatest potential to decrease inequities in alcohol consumption and alcohol-related harms include town planning, zoning and licensing to prevent disproportionate clustering of outlets in disadvantaged areas; interventions targeting licensed venues; and interventions targeting vulnerable populations. Interventions that may worsen inequities include national guidelines, technological interventions and public drinking bans. There is a need for further research into the best methods for reducing inequities in alcohol consumption and related harms.

Associations Between Socioeconomic Factors and Alcohol Outcomes

Socioeconomic status (SES) is one of the many factors influencing a person's alcohol use and related outcomes. Findings have indicated that people with higher SES may consume similar or greater amounts of alcohol compared with people with lower SES, although the latter group seems to bear a disproportionate burden of negative alcohol-related consequences. These associations are further complicated by a variety of moderating factors, such as race, ethnicity, and gender. Thus, among individuals with lower SES, members of further marginalized communities, such as racial and ethnic minorities and homeless individuals, experience greater alcohol-related consequences. Future studies are needed to more fully explore the underlying mechanisms of the relationship between SES and alcohol outcomes. This knowledge should be applied toward the development of multilevel interventions that address not only individual-level risks but also economic disparities that have precipitated and maintained a disproportionate level of alcohol-related consequences among more marginalized and vulnerable populations.

Patterns of Alcohol Consumption and Related Behaviors in Brazil: Evidence from the 2013 National Health Survey (PNS 2013)

This study uses data from a nationally representative household survey (the 2013 National Health Survey, n = 62,986) to describe patterns of alcohol consumption and related behaviors among Brazilian adults. Analyses include descriptive and multivariable Poisson regression for self-reports in the past 30 days of: drinking any alcohol, binge drinking, binge drinking 4 or more times, and driving after drinking (DD); as well as age of alcohol consumption initiation. Results show that current drinking prevalence was 26%, with an average age of initiation of 18.7 years. Binge drinking was reported by 51% of drinkers, 43% of whom reported binge drinking 4 or more times. Drinking and driving was reported by nearly one quarter of those who drive a car/motorcycle. Current drinking was more likely among males, ages 25-34, single, urban, and those with more education. Binge drinking was more likely among males, older age groups, and people who started drinking before 18. Drinking and driving was higher among males, those with more education, and rural residents. Those who binge-drink were nearly 70% more likely to report DD. All behaviors varied significantly among Brazilian states. Given their potential health consequences, the levels of injurious alcohol behaviors observed here warrant increased attention from Brazilian policymakers and civil society.

Associations of Alcohol Availability and Neighborhood Socioeconomic Characteristics With Drinking: Cross-Sectional Results From the Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND

Living in neighborhoods with a high density of alcohol outlets and socioeconomic disadvantage may increase residents' alcohol use. Few researchers have studied these exposures in relation to multiple types of alcohol use, including beverage-specific consumption, and how individual demographic factors influence these relationships.

OBJECTIVE

To examine the relationships of alcohol outlet density and neighborhood disadvantage with alcohol consumption, and to investigate differences in these associations by race/ethnicity and income.

METHODS

Using cross-sectional data (N = 5,873) from the Multi-ethnic Study of Atherosclerosis in 2002, we examine associations of residential alcohol outlet density and neighborhood socioeconomic disadvantage with current, total weekly and heaviest daily alcohol use in gender-specific regression models, as well as moderation by race/ethnicity and income.

RESULTS

Drinking men living near high densities of alcohol outlets had 23%-29% more weekly alcohol use than men in low density areas. Among women who drank, those living near a moderate density of alcohol outlets consumed approximately 40% less liquor each week than those in low density areas, but higher outlet densities were associated with more wine consumption (35%-49%). Living in highly or moderately disadvantaged neighborhoods was associated with a lower probability of being a current drinker, but with higher rates of weekly beer consumption. Income moderated the relationship between neighborhood context and weekly alcohol use.

CONCLUSIONS/IMPORTANCE

Neighborhood disadvantage and alcohol outlet density may influence alcohol use with effects varying by gender and income. Results from this research may help target interventions and policy to groups most at risk for greater weekly consumption.

Alcohol and Alcohol Effects: Constituting Causality in Alcohol Epidemiology

Taking cues from Science and Technology Studies, we examine how one type of alcohol epidemiology constitutes the causality of alcohol health effects, and how three realities are made along the way: (1) alcohol is a stable agent that acts consistently to produce quantifiable effects; (2) these effects may be amplified or diminished by social or other factors but not mediated in other ways; and (3) alcohol effects observable at the population level are priorities for public health. We describe how these propositions are predicated upon several simplifications and that these simplifications have political implications, including the attribution of responsibility for health effects to a pharmacological substance; the deletion of other agentic forces that might share responsibility; and a prioritization of simple effects over complex effects. We argue that epidemiological research on alcohol might expand its range of ontological, epistemological and methodological practices to identify new ways of understanding and addressing health effects.