Commentary on Huckle et al. (2010):Those confounding facts of lifestyleadd_3005 1203..1204

Over decades social epidemiological research has consis-tently documented a connection between socio-economicstatus (SES) and morbidity and mortality: those of lowerSES have poorer health and lower life expectancy thanthose of higher SES [1]. Health behaviours such asalcohol use and smoking are important mediatingmechanisms [2], but people of low SES are more vulner-able due to ‘the range of social circumstances that canaffect health through different pathways including acces-sibility to health care, exposure to environmental factors,health behaviour and lifestyle’ [3, p. 460].

The well conducted research by Huckle et al. [4] dem-onstrates the complexity of how SES relates to differentiallifestyle patterns (here, alcohol consumption) and howthese in turn relate to adverse outcomes. The authors firstshow that those of lower SES tend to drink more alcoholper occasion whereas those of higher SES tend to drinksmaller amounts but more frequently. Other researchershave also found this pattern for various countries [5–7].The authors go on to examine how SES is related toalcohol-related problems once alcohol consumption iscontrolled and gather that there is almost no connection.Thus, we come to the not surprising conclusion thatalcohol consumption is the major determinant ofalcohol-related problems. This result has been found pre-viously in the work of Selin [8], Cahalan & Room [9], andHilton [10]. In fact, Cahalan & Room [9] originated thistype of ‘two-step model’ stating that socio-demographicfactors are related to drinking patterns, but are not goodpredictors of alcohol consequences over and beyonddrinking.

To explore the results further, we must consider thestudy outcome. In alcohol survey research, the kind ofself-attributed alcohol consequences used by Huckle et al.[4] are common [11]. Some of these consequences arelikely to be familiar to anyone who ever drinks too much,e.g. ‘felt effects of alcohol the next day’, or ‘been ashamedof actions when drinking’. They could even be regardedas proxies of heavy drinking. Hence, it is no surprise thatSES has little direct association with them after drinkingpatterns are controlled.

Additionally, we are reminded of the ‘two worlds ofalcohol problems’ [12]: alcohol problems and those whohave them look very different if we consider populationsurveys, which describe the world of the fairly well func-tioning, or if we look at clinical populations. In the latter,the severity of the problems is greater, the history of theproblems longer, and there is a greater potential for soci-ety’s response to the drinking—or lack of it—to have

affected the outcome. Indicators of severe problems suchas mortality, hospitalisation or confrontation with policecannot typically be captured by surveys, but they can becaptured by research using police and health registries.The expectation would be that the connection to SES,even beyond the effect of drinking, would be stronger forsuch severe and chronic consequences for which the pro-cesses leading to the outcome are affected by a multitudeof different factors. Indeed Mäkelä & Paljäri [13] found asubstantial persistent effect of SES on alcohol-relatedmortality and hospitalisation after controlling for drink-ing pattern. Their results are similar to those found forSES and lung cancer incidence after smoking is controlledfor [3].

When considering all this, we think Huckleet al. [4] slightly downplayed their own results. Oninspection of Table 4 in their paper, one can see out-comes that are in accord with what is expected on thebasis of the aforementioned. The few significant resultsreported do not occur randomly. They are found for themore external or severe consequences of ‘alcohol-related disorder’ and ‘symptoms of dependence’—notfor the outcomes that could be interpreted as proxies forheavy episodic drinking (‘heavier drinking effects’, ‘felteffects the next day’). Furthermore, it is the mostdisadvantaged groups that are shown to suffer most ofthe first type of consequences with similar drinking.People with no qualification, the unemployed andthose with below average income thus have a doubleburden with regard to alcohol problems: not only dothey tend to drink more, but they also possess fewerresources to protect them from the ill effects of heavierdrinking.

What can we conclude in general about the relation ofSES to alcohol-related problems based on surveyresearch? Overall, there is a clear connection betweenlower SES and alcohol-related problems (when drinking isnot controlled for) [14]. This social fact carries importantinformation for public health policymakers, who thenneed to decide whether to direct efforts toward specificdrinking patterns that predict alcohol problems (e.g. heavyconsumption, heavy episodic drinking) or whether tofocus on specific subgroups that demonstrate a higherprevalence of such drinking habits. Insofar, Huckleet al.’s [4] findings remind us that alcohol drinking is themain risk factor for alcohol-related problems, but alsothat the social circumstances and lifestyle choices result-ing in that drinking remain significant factors not to beignored.

COMMENTARY

© 2010 The Authors. Journal compilation © 2010 Society for the Study of Addiction Addiction, 105, 1203–1204

Declarations of interest

None.

Keywords Alcohol consumption, alcohol-relatedproblems, health behaviour, socioeconomic status.

KIM BLOOMFIELD1 & PIA MÄKELÄ2

Centre for Alcohol and Drug Research (CRF), CopenhagenDivision, Aarhus University, Copenhagen, Denmark1 and

National Institute for Health and Welfare (THL), Helsinki,Finland2. E-mail: pia.makela@thl.fi

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1204 Commentary

© 2010 The Authors. Journal compilation © 2010 Society for the Study of Addiction Addiction, 105, 1203–1204