The alcohol harm paradox is the consistent research finding that the disadvantaged suffer greater rates of alcohol-related hospitalisations and deaths, even though they often consume less alcohol than the more advantaged. For example, in England 45% of people in the highest income bracket exceed the low-risk drinking guidelines. This compares to just 22% of those in the lowest income bracket. However, the rate of death attributed to alcohol consumption is 5.5 times higher for the poorest. So why are the disadvantaged suffering more while drinking less?

What could be the cause?

In our recent paper published in Addiction, we reviewed explanations for the alcohol harm paradox suggested within the scientific literature. We found 79 papers which were a mix of academic literature and government or third sector reports. There were 41 distinct explanations for the paradox which fit into six broad categories: lifestyle, artefact, individual, contextual, disadvantage, and upstream.

The most proposed explanation was that disadvantaged people engage in unhealthier behaviours which puts them at greater risk of harm: a lifestyle explanation. The most frequently suggested causes of the paradox were: that disadvantaged people drink more alcohol per occasion (even if they drink less overall), are more likely to smoke, and have an unhealthy diet. However, analyses of survey data suggest that these unhealthy behaviours only provide a partial explanation for the paradox, and the alcohol-related mortality and hospitalisation risk for disadvantaged people remains almost three-fold higher even when we take unhealthy behaviours into account.

Another explanation that received some research attention is that disadvantaged people drink more alcohol than they say they do when asked in health surveys. Therefore, the alcohol harm paradox doesn’t actually exist, it is an artefact of using self-report measures of alcohol consumption. However, studies that use biological indicators of alcohol consumption rather than self-report measures still find the paradox.

There were many other, mainly speculative, explanations for the alcohol harm paradox which remain untested. These include:

  • Explanations at the individual level (factors within individuals affecting susceptibility to harm)
  • Context (the impact of differences in their social and physical environment)
  • Disadvantage (how their own resources, access to healthcare, belonging to multiple minority groups and personal history/trajectories affect harm)
  • Upstream (the broader economic and political factors (e.g., policy) – which were less clearly connected to harm).

What should we do next?

It is not surprising research efforts to understand the alcohol harm paradox have largely focused on health behaviour; this has been a staple of health and epidemiological research and data is available for analysis in most health surveys. Calling for people to change their health behaviour puts emphasis on the individual to make the change and is an achievable goal, at least in theory. Unfortunately, a behaviour-focused approach is not going to be enough to tackle the unequal burden of alcohol harm even if it can be achieved in practice.

Inequalities in alcohol harm are just one example of many inequalities in health outcomes. The difference with alcohol is that consumption is higher among more advantaged groups, whereas more disadvantaged groups typically engage in more ‘unhealthy behaviours’. Given the entrenched social and health inequalities in high-income countries, perhaps the “paradoxical” patterns in alcohol harm are not surprising at all. Our future work aims to go beyond lifestyle explanations by drawing on existing health inequality theory to better understand the causes of the paradox.

Written by Jennifer Boyd, PhD student at the Wellcome Trust Doctoral Training Centre in Public Health, Economics and Decision Science, University of Sheffield

All IAS Blogposts are published with the permission of the author. The views expressed are solely the author’s own and do not necessarily represent the views of the Institute of Alcohol Studies.