The alcohol harm paradox – why are the poor at increased health risk?

Following the publication of research in BMC Public Health regarding the harm of alcohol on those with low socioeconomic status, we asked co-author of the work, James Nicholls, to explain more about their findings.

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At the start of January, the UK Chief Medical Officers announced new guidelines on low risk drinking. They recommend that, in order to reduce the lifetime risk of dying from an alcohol-related cause to less than 1%, men and women shouldn’t regularly consume more than 14 units of alcohol a week and should avoid drinking heavily on single occasions.

The announcement spurred debate about how health risks are calculated, communicated and interpreted: is a 1% mortality risk low or high, compared to other routine (or leisure) activities?

How should we balance short-term pleasure against potential long-term harm? Is the role of guidelines to inform consumers, to change behavior or to reset our measures of ‘risky’ drinking across the population?

These are all important questions. There is, however, a further question that matters in this context of detailed risk assessment: why is it that, despite drinking similar amounts on average, people in deprived communities are many more times likely to suffer alcohol-related disease and death than more affluent drinkers?

Why does alcohol cause more harm to the poor?

The figures are startling. In Scotland it is estimated that alcohol-related death rates in the most deprived communities are six times higher than in the most affluent.

The figures are startling. In Scotland it is estimated that alcohol-related death rates in the most deprived communities are six times higher than in the most affluent. The skew is only slightly less pronounced in England and Wales, and is seen throughout the developed world.

While some drinkers (including, perhaps, the ‘worried well’) may now be wondering whether they should ponder cancer risks every time they pour a glass of wine, fewer people are asking why alcohol health harms fall so disproportionately on the poor, why risk appears to be heavily skewed by socioeconomic factors, and what the full implications of this really are.

A new study in BMC Public Health addresses this question. Its findings touch on the possibility that the skew is – in part at least – to do with the interaction of health-influencing behaviors.

Part of a larger study of the ‘alcohol harm paradox‘, funded by Alcohol Research UK, the paper analyses data from a national survey and finds some potentially important associations between drinking, diet, smoking, exercise and deprivation.

Among more deprived drinkers, alcohol consumption is more likely to be combined with smoking and poor diet, suggesting a multiplicative effect in which combinations of behaviors amplify the health risks associated with any one of those activities.

The research also identifies higher levels of current and past ‘binge drinking’ among some deprived drinkers, which is known to weaken the protective effects of low consumption on, for example, ischaemic heart disease.

What else do we need to know?

We also know that poverty impacts on a range of health outcomes that overlap with partially alcohol-attributable conditions such as hypertension.

There remains, undoubtedly, much more work to do on this issue. We know, for instance, that surveys often suffer low response rates from very poor or marginalized individuals.

We also know that poverty impacts on a range of health outcomes that overlap with partially alcohol-attributable conditions such as hypertension. This paper is one contribution to untangling those complex interactions.

Hopefully, the more research we carry out the closer we will come to understanding the ‘harm paradox’. As alcohol-related harms rise up the policy agenda, we need to keep asking why those risks seem different if you’re poor.

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Joel thurm

Alcohol needs to be treated like a food in the sense that the contents of the bottle need to be fully explain and the metabolic implications written on the bottle

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