ReviewHow economic crises affect alcohol consumption and alcohol-related health problems: A realist systematic review
Introduction
In the public health community, concerns have been expressed about negative health consequences associated with the current economic crisis in Europe (WHO, 2009). This crisis started in 2008 as a result of decreasing mortgage-backed security values during previous years in the United States (US) (Obstfeld and Rogoff). In the US this led to rising interest rates, borrower and bank defaults, and a crash in the housing and stock markets. Because many of these mortgage-backed securities were sold in Europe, this also triggered an economic crisis there. Another trigger for the European economic crisis has been the collapse of the US import market, which produced serious consequences for the European export market and economy (Blanchard et al., 2010). From 2008 onwards, gross domestic product (GDP) decreased, unemployment rates increased, and public budget deficits rose substantially (Eurostat, 2012). In response to the economic crisis, many European countries introduced major policy changes (Karanikolos et al., 2013), which may have influenced public health on top of the influence that the economic decline itself may have had (Stuckler and Basu, 2013).
Alcohol consumption (in terms of volume and pattern) and alcohol-related health problems (e.g., alcohol abuse, and dependence) are public health issues that can be positively or negatively affected by economic crises. Changes in alcohol consumption can have a considerable effect on public health and societal welfare (Anderson et al., 2009), as total alcohol consumption is causally related to many chronic medical conditions like cancer, mental disorders, and cardiovascular diseases (Rehm et al., 2003, Rehm et al., 2008). Moreover, large numbers of drinking occasions and binge drinking can lead to either intentional or unintentional injuries, resulting from things such as violent behavior, suicide, homicide, and traffic accidents (Rehm et al., 2003; Taylor et al., 2008). There are also substantial indirect effects of alcohol-related health problems such as job loss, crime, and social exclusion (van Amsterdam and van den Brink, 2013).
The empirical evidence on the impact of economic crises on alcohol consumption and alcohol-related health problems is mixed. Alcohol consumption increased following the start of the economic and social transition in Russia and other Eastern European countries in the early 1990s, and this coincided with an increase in mortality and accidents (Baker, 2011, Men et al., 2003, Wojtyniak et al., 2005). This may be related to the strong binge drinking culture in Eastern Europe (Rechel et al., 2013). Moreover, the Gorbachev anti-alcohol campaign ended just before the start of the Russian transition, and this led to lower alcohol prices (Bhattacharya et al., 2013). During this same time period Finland experienced an economic crisis, which led to mass unemployment. However, in contrast with the transition in Eastern Europe, the crisis in Finland coincided with a reduction in alcohol consumption and alcohol-related mortality (Herttua et al., 2007, Hintikka et al., 1999, Valkonen et al., 2000). A reduction in alcohol consumption also followed the economic slowdown in Australia in the early 1990s (Chalmers and Ritter, 2011). The crisis in Southeast Asia in the late 1990s led to an increase in suicide rates, but alcohol consumption remained stable (Chang et al., 2009). These opposing trends support the notion that both specific characteristics of the crisis and the country-level context can influence how an economic crisis may exert an effect on alcohol consumption and alcohol-related health problems.
Economic crises can increase anxiety, stress, and depression (Wahlbeck and McDaid, 2012), for example, as a result of income reductions and/or loss of employment and the subsequent loss of social status and relationships. Two related psychological theories explain how these crises-triggered consequences could increase levels of alcohol consumption and the incidence of alcohol-related health problems. The “stress-response-dampening theory” argues that individuals consume alcohol to reduce the intensity of their response to anxiety and stress, which results in higher levels of alcohol consumption during economic crises (Sayette, 1999, Sher et al., 2007, Sher and Levenson, 1982). The “self-medication theory” argues that alcohol-related health problems may increase during economic crises because consuming alcohol to cope with such stressful situations can lead to the development of dependency in certain people (Bolton et al., 2009, Khantzian, 1997). Theories from other fields, including economics and sociology, offer different explanations. One basic economic theory suggests that income reductions will result in tighter individual budget constraints, so that less money will be spent on normal goods, including alcoholic beverages (i.e., the “income-effect theory”) (Catalano, 1997, Ruhm, 1995). According to the “non-working time theory”, a decrease in working hours (either due to job loss or fewer tasks at work) will lead to more time for social events, sports activities, and watching television. It is known that these activities are often accompanied by alcohol consumption (French et al., 2009). These theories may suggest that the impact of economic crises on alcohol consumption depends on a person's economic and social situation.
The contradictory empirical evidence and the variety of theories suggest that an economic crisis is a complex event that affects behavioral patterns (such as drinking) via various potentially opposing mechanisms. Therefore, the overall net impact is hard to predict and may well differ between countries and between subgroups within a population. To facilitate such predictions, we need evidence on which mechanisms play a role in which context and in which subgroup within a population. Such evidence would contribute to an understanding of how the current post-2008 economic crisis in Europe (but also other crises) may have had an impact on alcohol-related health problems. In addition, such evidence can help to determine which policies (e.g., increase in alcohol prices, or a restriction in alcohol availability (WHO, 2011)) can best be implemented during economic crises to change the presence of behavioral mechanisms and prevent an increase in the prevalence of excessive alcohol use. Such evidence can also be used to identify those subgroups most at risk of increased drinking during times of crisis.
In light of the above, the aim of our review was to investigate how economic crises affect levels of alcohol consumption and the incidence of alcohol-related health problems, and whom this affects. This was innovative, as little research is being done that assesses the role of specific mechanisms or tries to empirically discriminate between mechanisms (Catalano, 1997). The complexity of the topic makes a systematic review using the realist evaluation methodology (Pawson, 2006) suitable for our research question. The realist evaluation method tries to answer how, under what circumstances, and among whom certain policies or changed conditions have an effect on a specific outcome. It is a theory-driven method. First, an initial theoretical framework is constructed on how a changed condition can have an impact in a certain context and in certain subgroups within a population. The theoretical framework focuses on providing insight into the “inner workings” of a certain changed condition. Then, different types of evidence are collected to confirm, refute, or refine this initial theoretical framework. We used both quantitative and qualitative empirical evidence from different disciplines, including public health, social psychology, and economics.
Section snippets
Methods
According to Pawson (2006), a realist systematic review should follow six steps: 1) Identify the research question, 2) Formulate the initial theoretical framework, 3) Search for primary studies, 4) Select studies and appraise study quality, 5) Extract, analyze, and synthesize relevant data, and 6) Refine the theoretical framework. These six steps were applied throughout our paper. In addition, our research was guided by Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES)
Selection of papers
The flow diagram in Fig. 2 shows the selection of full text papers. Of the 87 included full text papers, 45 were excluded based on the defined criteria. Five additional full text papers were included after checking the references cited in the included papers. Twelve out of the 47 included studies provided only small evidence for a mechanism, and were therefore excluded from our results section. Study characteristics are presented in Table 1 (Appendix); the studies shaded in gray were not
Refining the initial theoretical framework and the strength of evidence
Our realist systematic review has found strong empirical evidence on several crises across many countries to support two behavioral mechanisms by which economic crises may exert an effect on alcohol consumption and alcohol-related health problems. These behavioral mechanisms are increased psychological distress and tighter budget constraints.
According to the first mechanism, people may drink more when they feel anxious, depressed, and frustrated. These presentations of psychological distress
Conclusion
More evidence is needed on how economic crises may exert an effect on alcohol-related outcomes. Although, we can conclude from this realist review that two opposing mechanisms may come into play during a crisis: reductions in alcohol consumption due to tighter budget constraints and a rise in harmful drinking due to increased psychological distress. The net impact among men seems to be an increase in levels of harmful drinking and in the incidence of alcohol-related health problems, possibly
Acknowledgments
The authors gratefully acknowledge Bregje van der Wouden for reviewing the quality of the included studies and coverage of evidence for the extracted mechanisms. This research was part of the SOPHIE project, which received funding from the European Community's Seventh Framework Programme (FP7/2007-2013) under grant agreement number 278173.
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