Lower socioeconomic groups generally consume less alcohol overall and contain a higher proportion of abstainers, but they experience higher levels of alcohol harm than wealthier groups in society with the same level of consumption.[i]
This is often referred to as the ‘Alcohol Harm Paradox’.[ii][iii] The ‘Alcohol Harm Paradox’ is evident in Ireland, where the Department of Health has stated that, while alcohol harm affects all social groups in Ireland, ‘the greater harm is experienced by marginalised and deprived groups’.[iv]
The Department of Health has also pointed out that alcohol-related hospital admissions in Ireland are significantly biased towards the poor and disadvantaged, reflecting the greater health harms they suffer.[v]
However, it’s not just those drinking in poorer communities that are more likely to suffer alcohol harm – those around them do too, with children most vulnerable. A HSE report found that those from lower socio-economic groups are more vulnerable to harm from others, particularly within the family.[vi]
Alcohol’s harm to others in Ireland states ‘those from lower social classes are more vulnerable to family problems due to others’ drinking, contributing to the health inequality gap’.[vii]
The greater levels of alcohol harm experienced by those in our poorer communities exist despite the fact that the Healthy Ireland Survey from 2015 confirmed that these communities have higher levels of abstention and lower overall levels of alcohol consumption.[viii]
The survey’s analysis of drinking behaviour using the National Deprivation Index shows that those living in the most deprived decile (10% of the population) are less likely (75%) to consume alcohol than those in the least deprived (84%). Widening out the analysis, alcohol consumption is lower amongst the three most deprived deciles than it is within the three least deprived. A similar pattern was found in terms of social class, with 81% of those in the higher groups (1 and 2) having drunk alcohol in the past 12 months, compared with 73% in the lower groups (5 and 6).
The frequency by which alcohol is consumed is also higher in less deprived areas and social classes than it is amongst more deprived areas and social classes. Almost two thirds (63%) of drinkers living in the least deprived areas drink at least once a week with 45% drinking multiple times each week. However, the equivalent figures for those living in the most deprived areas are lower, with 53% drinking at least once a week and 32% drinking multiple times each week.
While the Healthy Ireland Survey shows that both incidence and frequency of alcohol consumption is higher in less deprived areas than in more deprived areas, the same is not the case for the amount of alcohol consumed on single drinking occasions. Those living in more deprived areas are more likely to binge drink than those in less deprived areas.
The findings around binge drinking are the same in both in terms of the measures of typical drinking behaviour and frequency of binge drinking. Drinkers in the most deprived decile drink on average 6.1 standard drinks on a typical drinking occasion, compared with an average of 5.2 in the least deprived. The frequency of drinking six or more standard drinks is higher in more deprived areas (31% do so at least weekly) than less deprived (23%).
The greater levels of binge drinking, or heavy episodic drinking, among more deprived areas is important as the volume of alcohol consumed on a single occasion is important for many acute consequences of drinking such as alcohol poisoning, injury and violence, while it is associated with detrimental consequences even if the average level of alcohol consumption of the person concerned is relatively low.[ix]
Variations in the pattern of alcohol consumption, especially binge drinking, can have a stronger bearing on alcohol harm than overall alcohol consumption and drinkers in lower socioeconomic groups are more likely to binge drink.[x] The Healthy Ireland Survey results indicate that this may well be a factor in the ‘Alcohol Harm Paradox’ evident in Ireland.
As well as binge drinking, there are a number of other key issues to consider, as ‘inequities in other areas of life produce a compound effect in contributing to inequities in alcohol-related harm’. Experiencing several different aspects of socioeconomic disadvantage (e.g. personal income, education level and occupational level) worsens inequities in alcohol harm.[xi]
The WHO points out that ‘poor, socially excluded groups are more likely to have increased exposure to life stressors; have fewer buffering and coping resources; live in neighbourhoods with a higher density of alcohol sales outlets; have reduced access to affordable and appropriate support; experience greater adverse consequences for their household budget from alcohol consumption; live with or near people who also drink excessively; and are more likely to suffer co-morbidities such as mental health problems and other substance abuse disorders’.[xii]
A U.K. study of the ‘Alcohol Harm Paradox’ found that ‘deprived increased/higher drinkers are more likely than affluent counterparts to consume alcohol as part of a suite of health challenging behaviours including smoking, excess weight and poor diet/exercise’ and pointed out that ‘together these can have multiplicative effects on risks of wholly (e.g. alcoholic liver disease) and partly (e.g. cancers) alcohol-related conditions’, which greatly increases the risk of ill-health.[xiii]
This is certainly a concern in Ireland, where, as well as greater levels of binge drinking, the Healthy Ireland Survey showed that smoking levels are higher amongst those living in the most deprived areas and in lower social classes, with those living in the most deprived decile who are more than twice as likely to smoke (35%) compared to those living in the least deprived decile (16%). The survey found poorer diet and nutrition in more deprived areas, as well as amongst those with lower levels of education. There were also difference BMI across different areas, with the proportion that is obese higher in more deprived than less deprived areas.
As well as socio-economic conditions and lifestyle risk factors that increase the risk of alcohol harm, health outcomes for those from poorer communities is also another important factor. The WHO points out that ‘various health system factors can also cause certain groups to experience poorer health outcomes from alcohol-related conditions’.[xiv]
Inequalities exist in relation to both access to health care services and treatment for alcohol problems, which also helps to explain why people from poorer communities suffer greater harm, even though their levels of harmful alcohol consumption may be similar to their wealthier counterparts, who have far greater levels of access to health care and alcohol treatment services, among other supports.
The Irish Cancer Society has pointed out that death rates from cancers in some of the poorest parts of Dublin are twice as high as rates in more affluent areas. Access to healthcare remains a key issue in these poorer communities, along with higher prevalence – and less awareness – of the health risks associated with certain behaviours.
The WHO also notes that wealthier drinkers have ‘a wider social buffer to protect them from harm as a result of alcohol consumption’, while poorer drinkers are far more exposed to consequences such as imprisonment, unsafe sexual behaviour, job loss, social exclusion and injury.[xv]
[i] Loring B. Alcohol and inequities. Guidance for addressing inequities in alcohol-related harm. World Health Organisation; 2014.
[ii] Lewer D, Meier P, Beard E, Boniface S, Kaner E. Unravelling the alcohol harm paradox: a population-based study of social gradients across very heavy drinking thresholds. BMC Public Health. 2016;16(1):1-11.
[iii] Bellis MA, Hughes K, Nicholls J, Sheron N, Gilmore I, Jones L. The alcohol harm paradox: using a national survey to explore how alcohol may disproportionately impact health in deprived individuals. BMC Public Health. 2016;16(1):1-10.
[iv] Regulatory Impact Analysis. Public Health (Alcohol) Bill. Department of Health; 2015.
[v] Regulatory Impact Analysis. Public Health (Alcohol) Bill. Department of Health; 2015.
[vi] Hope A. Alcohol’s Harm to Others in Ireland. Health Service Executive; 2014.
[vii] Hope A. Alcohol’s Harm to Others in Ireland. Health Service Executive; 2014.
[viii] Healthy Ireland Survey 2015.Summary of Findings.: Department of Health.
[ix] Global status report on alcohol and health 2014. Geneva: World Health Organisation; 2014.
[x] Loring B. Alcohol and inequities. Guidance for addressing inequities in alcohol-related harm. World Health Organisation; 2014.
[xi] Loring B. Alcohol and inequities. Guidance for addressing inequities in alcohol-related harm. World Health Organisation; 2014.
[xii] Loring B. Alcohol and inequities. Guidance for addressing inequities in alcohol-related harm. World Health Organisation; 2014.
[xiii] Bellis MA, Hughes K, Nicholls J, Sheron N, Gilmore I, Jones L. The alcohol harm paradox: using a national survey to explore how alcohol may disproportionately impact health in deprived individuals. BMC Public Health. 2016;16(1):1-10.
[xiv] Loring B. Alcohol and inequities. Guidance for addressing inequities in alcohol-related harm. World Health Organisation; 2014.
[xv] Loring B. Alcohol and inequities. Guidance for addressing inequities in alcohol-related harm. World Health Organisation; 2014.