The alcohol harm paradox: Why do the poorest people in society experience the most alcohol-related harms if it is the richest people who drink the most alcohol?

As a child, my dad always told me: “Life isn’t fair. Then you pay taxes.”

As a wide eyed eight-year-old complaining about the injustice of having to share my Dream Phone boardgame with my sister, I didn’t know how right he was.

Twenty (something) years later and no longer plagued by memories of dreamphonegate – one of the injustices that riles me up most is the Alcohol Harm Paradox.

It goes as follows: The richest fifth of the country consume the most alcohol, but the poorest fifth of the country experience the most alcohol related harms.

The alcohol harm paradox

Doesn’t sound right does it? But unfortunately, the figures for the alcohol harm paradox speak for themselves. A 2015 Scottish government survey showed that of the wealthiest fifth of households, more than 45% of men drank to harmful levels compared to 25% of men in the most deprived households (Fig 1). Numbers are lower overall for women, but the difference between the two groups is consistent.

Alight, we can acknowledge that. But surely the group that boozes the most should also be the one experiencing the most problems, right? Wrong. 

Scottish hospital data show that there are far more hospital discharges for alcohol-related problems for the most deprived group compared with the wealthiest (Fig 2).

Stats also show that more people die of liver cirrhosis in the most deprived groups compared to the most affluent and that debt is associated with increased odds of alcohol and drug dependence.

So, what’s going on with this apparently nonsensical turn of events? Is alcohol secretly harbouring prejudices against the working classes?

Experts have drilled down into this phenomenon and come up with a couple of explanations.

When it comes to the harms we experience at the hands of the bottle, it is both drinking behaviour (i.e. sustained v binging) and quantity (actual number of units) that makes a difference.

Deprived groups tend to do more binge drinking than their wealthier counterparts. This means they’re more likely to get injured when boozing and there’s also a higher risk of heart disease.

But the story doesn’t end there. The difference in drinking patterns only accounts for 30% of the discrepancy.

The effects of drinking alcohol are heightened when there are other compounding factors. 

Those in deprived areas are more likely to be overweight and less likely to exercise regularly. You’re also four times more likely to smoke if you’re in a deprived area compared to a wealthy one.

Add these to bouts of binge drinking and the risk of alcohol-related harms is naturally going to be increased.

Another potential explanation is the availability of alcohol in deprived areas. Where I’m based in the UK alcohol is available just about everywhere, the chances are, it’s similar in your neighbourhood.

But research has shown that when you’re in a deprived area, you’ll find more shops selling booze – they’ll be dotted between the pawn shops and the bookies which are also more prevalent.

Where alcohol is more available, there is a higher rate of alcohol related harm – that’s also a well-documented fact.

As if we hadn’t just piled enough on top of the most deprived groups, there’s a cruel sting in the tail.

I work with people struggling with addictions and a couple of weeks ago I had a message from a woman who had heard me talk about the difficulties for those with a lower income.  

She told me she couldn’t afford transport to recovery meetings or childcare to allow her the freedom to attend them.

There are stacks of inspirational books to read on sobriety, but they’re not free. 

There are plenty of meetings which are free to attend if you can get to them but there’s little opportunity for one-on-one therapy for those who can’t afford to cough up for it.

Then don’t even think about an in-patient rehab centre. Referrals on the NHS are reserved for only the most severe and life-threatening cases and going it alone will set you back between £12,000-20,000 per month.

Alright, now I’ve convinced you that life’s not fair – it’s time to discuss what we can do about it.

The answer is SO much it’s hard to know where to start.

First things first, engaging with articles like this one, that give a new perspective is important, understanding the issues and bringing them up in conversation. Nothing will change while no one’s aware.

Second, challenge yourself – how empathetic are you? Addiction, alcohol use disorder and the working classes are not very sexy topics. There’s a mainstream narrative that this stuff is all the individual’s fault and we need to pull ourselves up by our bootstraps.

The fact is, you are a product of your environment whether you like it or not. If everyone around you smokes and binge drinks, you will too. This is not a blame game situation.

Third, and more practically, you can give your time and money to charities that shed a light on these issues and help individuals break the cycle. Forward Trust, Action on Addiction and Turning Point are a few I know of but there are LOADS out there.

Finally, there are a number of things the government can do and you can write about these to your MP. Research suggests: minimum unit pricing, reducing the number of alcohol licences handed out to premises, effective protection of young people from alcohol marketing and many more. Hold tight – they’ll be more on each of these as this series on activism continues.

If you’re newly sober or considering it, this may be the time to just focus on yourself, invest in self-care and take it easy on this journey.

But if – like me – the prospect of people from disadvantaged backgrounds suffering even more from alcohol fills your belly with the rage of a thousand suns, it could be time for activism.

Written by Lauren Windle

Lauren Windle is a journalist, presenter, and author. She’s been sober since April 2014, has a Masters in Addiction Studies from King’s College London and runs a support programme for anyone seeking recovery from addiction in West London. You can connect with her on Instagram and Twitter @_Lauren_Celeste.