@article{ref1,
title="Joint effects of alcohol use, smoking and body mass index as an explanation for the alcohol harm paradox: causal mediation analysis of eight cohort studies",
journal="Addiction",
year="2021",
author="Härkänen, Tommi and Laatikainen, Tiina and Makela, Pia and Peña, Sebastián and Koskinen, Seppo and Heliövaara, Markku and Männistö, Satu",
volume="ePub",
number="ePub",
pages="ePub-ePub",
abstract="BACKGROUND AND AIMS: Lower socioeconomic status (SES) is associated with higher alcohol-related harm despite lower levels of alcohol use. Differential vulnerability  due to joint effects of behavioural risk factors is one potential explanation for  this &quot;alcohol harm paradox&quot;. We analysed to what extent socioeconomic inequalities  in alcohol-mortality are mediated by alcohol, smoking and body mass index (BMI), and  their joint effects with each other and with SES. <br><br>DESIGN: Cohort study of eight  health examination surveys (1978-2007) linked to mortality data. SETTING: Finland  PARTICIPANTS: 53,632 Finnish residents aged 25+. MEASUREMENTS: The primary outcome  was alcohol-attributable mortality. We used income as an indicator of SES. We  assessed the joint effects between income and mediators (alcohol use, smoking and  BMI) and between the mediators, adjusting for socio-demographic indicators. We used  causal mediation analysis to calculate the total, direct, indirect and mediated  interactive effects using Aalen's additive hazards models. <br><br>FINDINGS: During  1,085,839 person-years of follow-up, we identified 865 alcohol-attributable deaths. We found joint effects for income and alcohol use and income and smoking, resulting  in 46.8 and 11.4 extra deaths due to the interaction per 10,000 person-years. No  interactions were observed for income and BMI or between alcohol and other  mediators. Lowest compared with highest income quintile was associated with 5.5  additional alcohol deaths per 10,000 person-years (95% CI 3.7; 7.3) after adjusting  for confounders. The proportion mediated by alcohol use was negative (-69.3%),  consistent with the alcohol harm paradox. The proportion mediated by smoking and BMI  and their additive interactions with income explained 18.1% of the total effect of  income on alcohol-attributable mortality. <br><br>CONCLUSIONS: People of lower socioeconomic  status appear to be more vulnerable to the effects of alcohol use and smoking on  alcohol-attributable mortality. Behavioural risk factors and their joint effects  with income may explain part of the alcohol harm paradox.<p /> <p>Language: en</p>",
language="en",
issn="0965-2140",
doi="10.1111/add.15395",
url="http://dx.doi.org/10.1111/add.15395"
}