Alcohol and inequalities

Drinking excessively can harm anyone. However, alcohol rarely works alone in causing health problems. The effects of alcohol are linked to a range of other factors: some individual, such as metabolism or inherited genetic traits; other environmental, such as diet, smoking, access to healthcare or stress. It is partly because the harmful effects of alcohol are linked to these other factors that we see a social gradient in alcohol harms.

On average, people on low incomes drink less than people on higher incomes. This is not surprising, since affordability is a key driver of consumption. However, people living in deprived areas are many times more likely to experience an alcohol-related hospital or die of an alcohol-related cause. In Scotland, for example alcohol-related deaths are six times higher in the most deprived areas compared to the least deprived.

Similar patterns are seen in many other countries. This phenomenon is often called the ‘alcohol harm paradox’.

Recently, a number of researchers have investigated the possible reasons behind this apparent paradox. The findings vary, and each probably point to one key aspect.

The relationship between alcohol with other factors influencing health

The effects of alcohol on the body are interactive: they relate to diet, general fitness, smoking and so forth. A study led by Liverpool John Moores University found that when alcohol, poor diet and smoking were combined, the risk of alcohol-related conditions increased significantly. It concluded that higher rates of smoking, and lower levels of nutrition, were a significant factor in amplifying the harmful outcomes of drinking in poorer communities.

The harm paradox is based on the average amounts consumed across different income groups. However, when analysed on more detail we find that there are much higher levels of non-drinking in more deprived areas – but also higher levels of very heavy drinking. Poorer areas tend to have much higher numbers of people with complex needs, and a lack of services that can support those people. A recent study found that these patterns were also a key factor in explaining the paradox.

However, when taking all these factors into account, researchers at the University of Glasgow found that, irrespective of how much an individual drank, what they ate, or whether they smoked, poorer people were still more likely to suffer alcohol harms. Indeed, they found – however deprivation was measured – moderate drinkers of low socioeconomic status were at more risk than people who drank heavily but were more affluent. They concluded that poor material circumstances and psychosocial stresses linked to poverty made people more susceptible to ill-health, regardless of other influences.

Researchers at Edinburgh University have looked in detail at the way alcohol is sold in different areas. They found that there is often a far higher concentration of shops selling alcohol in the poorest neighbourhoods. Wider research has tended to find that higher levels of ‘outlet density’ is linked to both higher levels of consumption and health harms. The implication of these findings, then, is that the ‘harm paradox’ is partly linked to a greater saturation of outlets – especially smaller shops selling very cheap alcohol – which, in turn facilitates higher levels of consumption.

More deprived areas often also suffer from fewer public services, including alcohol treatment provision. Research by Alcohol Change UK has found that many deprived areas have experienced significant cuts to treatment budgets, and so the problems of the ‘harm paradox’ are exacerbated. Given what we know about the increased problems linked to social deprivation and exclusion, more deprived areas should have access to increased treatment support rather than as is often the case, even less provision than is available elsewhere.

Understanding the role of social inequalities in driving alcohol harms is of critical importance. If we can target policy and interventions so that they impact on this social group, we can reduce harms where they are often most acute.

Minimum unit pricing, for example, is predicted to have particular benefits in deprived areas by reducing the availability of the very cheap, very strong alcohol that is associated with some of the most problematic drinking. Licensing authorities are increasingly taking the density of small off-licences into account in their decision-making, especially in Scotland where the promotion of public health is a formal element of the licensing process. Finally, a number of local areas have explored the use of ‘assertive outreach’ to bring some of the most socially excluded drinkers into treatment, thereby bridging a gap that otherwise can leave very vulnerable people without any support.

Without considering the social gradient linked to alcohol harms, we are only looking at part of the picture. We are closer to understanding the ‘harm paradox’ than previously, but still some way from implementing policies that may help to resolve it.

Further resources

Bellis, M et al. Understanding the alcohol harm paradox

World Health Organisation Europe. Alcohol and inequities