Public Health Ontario, Toronto, Ontario, Canada and.
Dalla Lana School of Public Health, University of Toronto, Ontario, Canada.
Epidemiology. 2024 Jan 1;35(1):64-73. doi: 10.1097/EDE.0000000000001674. Epub 2023 Nov 27.
Individuals with low socioeconomic position (SEP) experience disproportionately greater alcohol-attributable harm than individuals with high SEP despite similar or less alcohol use (i.e., the alcohol harm paradox). We examined the sex/gender- specific independent and joint effects of education and heavy drinking or volume of alcohol use on 100% alcohol-attributable hospitalization or death.
We conducted a cohort study among 199,125 current and former alcohol users aged 15-64 years from population-representative Canadian Community Health Surveys (2000-2008) linked to hospitalization and mortality records through 2017. We estimated the sex/gender-specific associations between education and heavy drinking or volume of alcohol use and incident 100% alcohol-attributable hospitalization or death using multivariable Fine and Gray subdistribution hazard models with competing risk (non-100% alcohol-attributable deaths), assessing additive interactions using the Synergy Index (S).
Overall, heavy drinking prevalence and volume of alcohol use were similar or lower in individuals with lower education compared with higher education. Lower education levels compared with a bachelor's degree or above were associated with increased 100% alcohol-attributable hospitalization or death [e.g., less than high school, men: hazard ratio (HR) = 2.78; 95% CI = 2.17, 3.56; women: HR = 2.98; 95% CI = 2.00, 4.44]. We found superadditive joint effects between low education and heavy drinking (men: S = 1.22; 95% CI = 1.14, 1.30; women: S = 1.34; 95% CI = 0.88, 2.04) and low education and higher volume of alcohol use (e.g., excess volume, men: S = 1.30; 95% CI = 1.05, 1.62; women: S = 1.41; 95% CI = 0.77, 2.58), with larger inequities in women than men with similar alcohol use.
Our study is consistent with the hypothesis that increased vulnerability to alcohol use among individuals with lower education partially explains the alcohol harm paradox in Canada.
尽管低社会经济地位（SEP）个体的酒精使用量与高 SEP 个体相似或更少，但他们遭受的与酒精相关的伤害却不成比例地更大（即酒精危害悖论）。我们研究了教育程度以及重度饮酒或酒精使用量对 100%归因于酒精的住院或死亡的独立和联合影响，并考虑了性别差异。
我们对来自具有代表性的加拿大社区健康调查（2000-2008 年）的 199125 名 15-64 岁的现职和前酒精使用者进行了队列研究，并通过 2017 年的住院和死亡率记录将其与这些记录相关联。我们使用多变量 Fine 和 Gray 亚分布风险模型（考虑竞争风险[非 100%归因于酒精的死亡]）来估计教育程度与重度饮酒或酒精使用量与 100%归因于酒精的住院或死亡的发生率之间的关联，使用协同指数（S）评估相加交互作用。
总体而言，与接受高等教育的个体相比，受教育程度较低的个体的重度饮酒流行率和酒精使用量相似或更低。与学士学位或以上学历相比，教育程度较低与 100%归因于酒精的住院或死亡风险增加有关[例如，未完成高中学业：男性，危险比（HR）=2.78；95%置信区间（CI）=2.17，3.56；女性，HR=2.98；95%CI=2.00，4.44]。我们发现低教育程度与重度饮酒（男性：S=1.22；95%CI=1.14，1.30；女性：S=1.34；95%CI=0.88，2.04）以及低教育程度与较高酒精使用量（例如，过量饮酒）之间存在超相加的联合效应（男性：S=1.30；95%CI=1.05，1.62；女性：S=1.41；95%CI=0.77，2.58），而且女性的不公平程度大于男性，尽管她们的酒精使用量相似。
我们的研究结果与假设一致，即较低教育程度的个体对酒精的易感性增加部分解释了加拿大的酒精危害悖论。
