The socioeconomic gradient of alcohol use: an analysis of nationally representative survey data from 55 low-income and middle-income countries

Xu Y. Geldsetzer P. Manne-Goehler J. Theilmann M. Marcus M.-E. Zhumadilov Z. Quesnel-Crooks S. Mwalim O. Moghaddam S.S. Koolaji S. Karki K.B. Farzadfar F. Ebrahimi N. Damasceno A. Aryal K.K. Agoudavi K. Atun R. Bärnighausen T. Davies J. Jaacks L.M. Vollmer S. Probst C.
September 2022 Elsevier Ltd

The Lancet Global Health
2022 #10 Issue 9 e1268 - e1280 pp.

Background: Alcohol is a leading risk factor for over 200 conditions and an important contributor to socioeconomic health inequalities. However, little is known about the associations between individuals’ socioeconomic circumstances and alcohol consumption, especially heavy episodic drinking (HED; ≥5 drinks on one occasion) in low-income or middle-income countries. We investigated the association between individual and household level socioeconomic status, and alcohol drinking habits in these settings. Methods: In this pooled analysis of individual-level data, we used available nationally representative surveys—mainly WHO Stepwise Approach to Surveillance surveys—conducted in 55 low-income and middle-income countries between 2005 and 2017 reporting on alcohol use. Surveys from participants aged 15 years or older were included. Logistic regression models controlling for age, country, and survey year stratified by sex and country income groups were used to investigate associations between two indicators of socioeconomic status (individual educational attainment and household wealth) and alcohol use (current drinking and HED amongst current drinkers). Findings: Surveys from 336 287 participants were included in the analysis. Among males, the highest prevalence of both current drinking and HED was found in lower-middle-income countries (L-MICs; current drinking 49·9% [95% CI 48·7–51·2] and HED 63·3% [61·0–65·7]). Among females, the prevalence of current drinking was highest in upper-middle-income countries (U-MIC; 29·5% [26·1–33·2]), and the prevalence of HED was highest in low-income countries (LICs; 36·8% [33·6–40·2]). Clear gradients in the prevalence of current drinking were observed across all country income groups, with a higher prevalence among participants with high socioeconomic status. However, in U-MICs, current drinkers with low socioeconomic status were more likely to engage in HED than participants with high socioeconomic status; the opposite was observed in LICs, and no association between socioeconomic status and HED was found in L-MICs. Interpretation: The findings call for urgent alcohol control policies and interventions in LICs and L-MICs to reduce harmful HED. Moreover, alcohol control policies need to be targeted at socially disadvantaged groups in U-MICs. Funding: Deutsche Forschungsgemeinschaft and the National Center for Advancing Translational Sciences of the US National Institutes of Health.

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School of Economics and Management, Gottfried Wilhelm Leibniz University of Hannover, Hannover, Germany
Faculty of Management and Economics, Ruhr University Bochum, Bochum, Germany
Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, CA, United States
Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, United States
Harvard Center for Population and Development Studies, Harvard University, Cambridge, Boston, MA, United States
Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
Department of Global Health and Social Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
Department of Economics and Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan
Non-Communicable Diseases, Caribbean Public Health Agency, Port of Spain, Trinidad and Tobago
Ministry of Health, Zanzibar City, Tanzania
Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
Non-Communicable Diseases Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
Department of Community Medicine and Public Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
Nepal Health Sector Programme 3/Monitoring Evaluation and Operational Research, Abt Associates, Kathmandu, Nepal
Ministry of Health, Lome, Togo
Africa Health Research Institute, Somkhele, South Africa
Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
Global Academy of Agriculture and Food Security, The University of Edinburgh, Easter Bush Campus, Midlothian, United Kingdom
Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada
Department of Psychiatry, University of Toronto, Toronto, ON, Canada

School of Economics and Management
Faculty of Management and Economics
Division of Primary Care and Population Health
Department of Global Health and Population
Harvard Center for Population and Development Studies
Division of Infectious Diseases
Department of Global Health and Social Medicine
Heidelberg Institute of Global Health
Department of Economics and Centre for Modern Indian Studies
Nazarbayev University School of Medicine
Non-Communicable Diseases
Ministry of Health
Endocrinology and Metabolism Research Center
Non-Communicable Diseases Research Center
Department of Community Medicine and Public Health
Faculty of Medicine
Nepal Health Sector Programme 3/Monitoring Evaluation and Operational Research
Ministry of Health
Africa Health Research Institute
Institute of Applied Health Research
Centre for Global Surgery
Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit
Global Academy of Agriculture and Food Security
Institute for Mental Health Policy Research
Department of Psychiatry

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