With homelessness back in the spotlight following Prime Minister Andy Burnham’s pledge to end rough sleeping in England, an important question remains: do we fully understand the scale and nature of alcohol-related harms experienced by people without a stable place to live?
When we think about alcohol harm in England, we often turn to national surveys for answers. But there is a problem: some of the people most affected by alcohol-related harm are frequently missing from these datasets.
One of these groups excluded from routine household surveys are people experiencing homelessness. When people are left out of the data, services are not designed for them. Therefore, counting everyone and listening to their stories is essential if support is to reflect real needs.
Two recent studies sought to address this gap. One used dedicated survey data collected from more than 2,600 people experiencing homelessness in England to compare rates of alcohol use with those reported in a routine national household survey and assess the support people received. The other examined people’s trajectories of alcohol use, homelessness, treatment and potential recovery through 32 interviews with people experiencing homelessness who were currently or previously drinking at harmful levels. Together, they paint a picture of substantial unmet need but also offer important insights into what helps people move towards recovery.
Similar likelihood of drinking, very different levels of harm
We found that around 78% of people experiencing homelessness had consumed alcohol in the previous year. This was broadly similar to the 83% observed among adults living in private households (based on data from the 2022 Health Survey for England). The difference emerged when we looked beyond whether people drank and examined how much they drank.
Around one in three people experiencing homelessness exceeded the UK’s low-risk drinking guidelines of no more than 14 units of alcohol per week, compared with around one in four adults in private households. More strikingly, approximately one in five met criteria for possible alcohol use disorder, compared with fewer than one in twenty in the general population.
The findings also challenge the idea that homelessness is a single experience. The highest levels of risk were found among people sleeping rough. Nearly half exceeded drinking guidelines and more than a third met criteria for possible alcohol use disorder. Risk of alcohol use disorder also increased with the number of different forms of homelessness a person had experienced. This suggests that housing instability itself may accumulate over time, increasing vulnerability to alcohol-related harm.
Links between alcohol and homelessness
The interviews then helped explain why rough sleeping was associated with both the highest levels of alcohol-related harm and the lowest access to support. Participants described recovery as extraordinarily difficult when basic needs such as safety, shelter and stability remained unmet.
One participant recalled turning to alcohol during his first experience of homelessness to cope with the harsh conditions of sleeping rough:
It was winter as well. So, from the moment I woke up, I had myself drinking. So, it helped me keep myself feeling warmer.
Importantly, participants did not describe a single pathway linking alcohol and homelessness. For some, heavy drinking preceded housing loss. For others, drinking escalated after becoming homeless. These different trajectories suggest that simplistic explanations miss the complexity of people’s lives and support needs. For many people it is a cycle, where alcohol-related harms, trauma, poor mental and physical health, and housing instability reinforce one another.
A considerable treatment gap
One of the most concerning findings from our survey study relates to support and treatment.
More than a quarter of participants identified themselves as having had an alcohol problem at some point in their lives. Yet only around 58% of them reported receiving support.
The situation was particularly worrying for people sleeping rough. Despite having the highest levels of alcohol-related need, they were around four times less likely to receive support than people who had recently moved into their own tenancy. In short, those with the greatest need often face the greatest barriers to accessing support.
One participant explained how the lack of stable housing made it difficult to focus on recovery:
I can’t do nothing with alcohol or better myself without having a place where I can put my head down… when I’m out there, alcohol is always on my mind.
This reflects a wider theme across the interviews: for many participants, obtaining stable housing was not the end point of recovery but one of the conditions that made recovery possible.
Recovery is personal, but support matters
Participants described recovery as a deeply personal process rather than a single event. Many emphasised the importance of developing motivation for change, learning to view themselves with greater compassion, and reaching a point where change felt possible. Recovery was described less as a single intervention and more as a gradual process involving internal motivation, self-understanding, stability, and support.
As one participant reflected:
Understanding myself, learn to trust myself, learn to love myself… I see stability in my life now. It is manageable.
Several participants described periods when support was available, but they were not yet ready to engage with it. This suggests that improving outcomes may require services that remain flexible and available over time.
As one participant explained:
They sent me rehab. But because I think I wasn’t ready, I ended up leaving early.
A notable finding was that participants rarely described a single ‘best’ approach to treatment. Some valued mutual aid groups, others preferred structured rehabilitation and biomedical approaches.
Looking ahead
The UK Government has recently increased investment in drug and alcohol treatment services, including dedicated funding for people sleeping rough. Whether this will be sufficient remains to be seen.
What is clear from these two studies is that alcohol-related harm among people experiencing homelessness is not evenly distributed. People sleeping rough and those with more complex histories of homelessness face particularly high risks while simultaneously being less likely to access help.
If we are serious about reducing alcohol harms and health inequalities, we need services that are both accessible and responsive to the realities of homelessness. But treatment support alone is not enough. Wider social and commercial conditions shape our health: the availability of affordable housing, poverty and financial insecurity, access to healthcare, and an environment in which alcohol – an addictive substance – remains cheap, normalised and widely accessible. Addressing alcohol-related harm among people experiencing homelessness therefore requires action at both the individual and structural level.
Ultimately, the two studies remind us that people experiencing homelessness are not only at greater risk of alcohol-related harm, but they are also at risk of becoming invisible in the evidence used to shape policy. If we want effective responses to alcohol harm, we need to count everyone, listen to their experiences, and design systems around the realities of their lives.
The findings also highlight an important challenge for efforts to end rough sleeping: helping people into housing is vital, but sustained progress will also depend on addressing the wider issues many people face, including alcohol dependence and other complex support needs.
You can read the full open-access papers in BMJ Public Health here and in Addiction here.
Written by Dr Vera Buss, Senior Research Fellow, Department of Behavioural Science and Health, UCL, and Behavioural Research UK.
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.