Understanding the alcohol harm paradox

A new report from the Centre for Public Health at Liverpool John Moores University investigates the alcohol harm paradox.

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It is well established that people who live in more deprived communities or who have fewer personal socioeconomic resources are much more likely to die or suffer from a range of diseases, including those related to alcohol. For example, males and females in the most socioeconomically deprived neighbourhoods of the UK have been estimated to be two to three times as likely to die from an alcohol-related condition than their counterparts living in the least deprived. However, this is not simply due to differences in alcohol consumption, as surveys suggest that overall consumption is similar across groups.

This observation, that deprived populations that apparently consume the same or less alcohol than more affluent populations suffer far greater levels of harm, we have termed the alcohol harm paradox.

The paradox may arise for a number of reasons; including differences in drinking patterns, clustering of risk factors that lead to disease in more deprived populations (e.g. diet, smoking, stress), differences in neighbourhood resources (e.g. access to good quality health care, the number of local alcohol outlets), and alcohol related ill health leading to deprivation due to a loss of employment opportunities. Furthermore, it is well known that respondents of surveys investigating alcohol use tend to underestimate their consumption, and this may differ between people in different socioeconomic groups.

In important new work published today researchers from the Centre for Public Health (CPH), Liverpool John Moores University, investigated the paradox in more detail. The research was funded by Alcohol Research UK, (http://alcoholresearchuk.org/), and led by Lisa Jones, Reader in Public Health Evidence Synthesis, with major contributions from Mark Bellis (Visiting Professor at CPH), Ellie McCoy (Researcher in Public Health Synthesis), Harry Sumnall (Professor in Substance Use) and other CPH colleagues.

The research programme included a number of systematic reviews of existing evidence examining deprivation and alcohol use, reanalysis of an existing household alcohol use survey, and a new telephone survey in England which used a new methodology in order to capture alcohol use not ordinarily reported in other surveys.

Main findings included:

  • Lower socioeconomic status (SES) is associated with an almost two fold greater risk of alcohol related death compared with individuals in higher SES classifications.
  • Relative to high SES, low SES is associated with an increased risk of head and neck cancers, strokes, hypertension, liver disease and pre-term birth. These findings are independent of a number of other known risk factors for these conditions such as diet and smoking.
  • In general, although people in different SES groups did not differ in the number of units drunk or the frequency of use across the week, there are important differences in ‘binge drinking’, beverage choice, and patterns of heavy drinking. Compared with more affluent groups, people in lower SES groups tended to binge more, and individuals with lower educational qualifications tended to drink more and binge more frequently.
  • There was strong evidence of underreporting of alcohol use in general population surveys of alcohol use, but this differs by alcohol risk rather than SES. The use of alternative survey methodologies captures a greater amount of population alcohol use. This also leads to more people being classified as at increasing and higher risk from their alcohol use, which has important health policy implications.

Overall, the research supported the existence of the alcohol harm paradox. Alcohol policy options such as minimum unit pricing (MUP) have been shown by other researchers to target hazardous and harmful drinkers in lower socio economic groups without financially penalising moderate drinkers. MUP and the use of local licensing powers may be one means of reducing the disproportionate burden of alcohol related harms on less affluent individuals and communities.

Dr James Nicholls, Director of Research and Policy Development for Alcohol Research UK said of the research:

“The ‘alcohol harm paradox’ is of enormous significance. Understanding why harms fall disproportionately on the poorest in society is critical to both reducing health inequalities and tackling the burden of alcohol-related harms. This study makes a significant contribution to our understanding of this question, and outlines many of the gaps that still need to be filled. It shows clearly why this issue should be at the forefront of both research and policy, and reminds us of the need to look closely at the patterns and contexts of drinking across society when seeking to understand the problems alcohol can cause.”

Dr Nick Sheron, Head of Clinical Hepatology at the University of Southampton and member of the advisory group for the research also commented:

“This important study from Lisa Jones, Mark Bellis, Harry Sumnall and team at the Centre for Public Health tackles two of the most important and intriguing mysteries in alcohol research.

  • Firstly, where are the missing units? Only half of the units recorded from taxation can be accounted for by survey data, so who drinks the rest.
  • Second, why is it that the more people earn the more they drink, but alcohol related harm and ill health impact on the poorest most deprived sections of society up to nine times more than on the rich?

This imaginative study, funded by Alcohol Research UK, has pushed forward our knowledge in this critically important field, and provides crucial evidence that can help tackle health inequalities in our society.”

The full report can be read at Alcohol Research UK and also on the CPH website.

For further information or press interviews about the report content please contact Professor Harry Sumnall via the CPH press office by email j.lovelady@ljmu.ac.uk or telephone 0151 231 4107.