We know from several research studies that lower socioeconomic groups – categorised by having a lower income, no qualifications and living in the most deprived areas – suffer greater rates of alcohol-related hospitalisation and deaths. This is despite the fact that socioeconomically disadvantaged groups drink less alcohol on average than the more advantaged. For example, in England 45% of people in the highest income group exceed the low-risk drinking guidelines compared to just 22% in the lowest income group. However, the rate of alcohol-related death is 5.5 times higher for the poorest. This consistent finding has been coined the ‘Alcohol Harm Paradox’.
What do we know about the contribution of health behaviour?
Cross-sectional studies which provide a snapshot in time, have attempted to explain the relationship between socioeconomic position and alcohol harm by investigating the differences in health behaviours between groups. However, these studies fall short in being able to tell us how much these differences in health behaviour contribute to socioeconomic inequalities in alcohol harm. To our knowledge there are only three existing studies which use linked data methods – where individuals are asked about their socioeconomic position, alcohol consumption and other health behaviours, and this data is linked to their health records. These studies have been carried out in Scotland, Wales and Finland, and look at the contribution of heavier drinking patterns, smoking, poor diet and beverage type.
In our study published in SSM – Population Health, we use linked data from the English population of the UK Biobank to investigate first whether the Alcohol Harm Paradox is present in the dataset, and secondly, to test the contribution of drinking history, beverage type, BMI and smoking to socioeconomic inequalities in alcohol harm.
What did we find?
We found evidence of the paradox in our study. When we accounted for age, sex, ethnicity, previous alcohol-related hospital admission, and average alcohol consumption, people in the most deprived group experienced 48% higher rates of alcohol-related harm than those in the least deprived. Meaning that average alcohol consumption could not explain alcohol-related harms for the most deprived.
When we accounted for additional measures related to drinking, specifically whether people had stopped drinking for health reasons and their preferred alcoholic beverage, people in the most deprived group still experienced 41% higher rates of alcohol-related harm. However, when we also included smoking status and BMI this further reduced to 28%. This suggests that people in lower socioeconomic groups may experience higher rates of harm due to being more likely to smoke and have an unhealthier diet and/or engage in less physical activity which leads to greater BMI.
Our study demonstrates that health behaviours do explain some of the Alcohol Harm Paradox, but cannot fully explain the socioeconomic inequalities we observe in alcohol-harm.
What should we do next?
While our study suggests that attempts to improve health behaviour could reduce alcohol-related inequalities in harm, significant differences in harm cannot be explained by health behaviour alone. Existing work points to a lot of possible explanations for the Alcohol Harm Paradox including the impact of differences from the social and physical environment, individual’s own resources, access to healthcare, and the broader economic and political factors which remain based mostly on speculation rather than research findings. Future work should aim to start to test these alternate explanations to better understand the causes of the paradox.
Written by Dr Jennifer Boyd, Research Assistant, Social and Public Health Sciences Unit, University of Glasgow.
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.