The consumption of alcohol is a public health issue because it is one of the leading risk factors to health globally, says Elisabeth Morgans from C3 Collaborating for Health
The consumption of alcohol is a public health issue because it is one of the leading risk factors to health globally.
The public health issue
In 2016, it resulted in approximately 3 million deaths (5.3% of all deaths) globally and 132.6 million disability-adjusted life years (DALYs) – i.e., 5.1% of all DALYs in that year. 1 Furthermore, its effects are far reaching – harmful consumption of alcohol has a direct impact on several Sustainable Development Goal targets including maternal and child health, infectious diseases (HIV, viral hepatitis, tuberculosis), noncommunicable diseases and mental health, injuries and poisonings.1 These statistics and the direct and indirect effects on other global targets have driven a global need to unpack the complexity of the issue, not least for health policy makers and health leaders. There are multiple mechanisms through which alcohol directly influences health that include: the cumulative effects of consumption of alcohol; acute alcohol intoxication resulting in accidents, injuries and poisoning; and the effects resulting from alcohol impairment, and violence.2 But the complexity in understanding the impact of alcohol on health, and subsequently how to design interventions, is amplified by the relationship between alcohol and socioeconomic status.
Alcohol and inequality
According to the World Health Organisation, in most European countries, the difference in alcohol-related deaths and associated health problems between different socioeconomic groups, is significantly more stark, than the difference in alcohol consumption between these different groups.3 Alcohol may cause harm across the socioeconomic spectrum. However, when viewing the issue of alcohol and health through the lens of inequality, it is the issue of harm rather than consumption in which a strong social gradient exists.
Indeed, it is widely acknowledged that individuals on lower incomes drink less than people on high incomes, an unremarkable, and somewhat expected observation considering the issue of affordability – a principle driver of consumption. But, people living in deprived regions are far more likely to suffer from alcohol-related harm and alcohol-related deaths.4 In Scotland in 2015, rates of alcohol-related deaths were six times higher in the most deprived regions compared to the least deprived areas – a phenomena referred to as the ‘alcohol harm paradox’.5 The complexity of the paradox is reflected by its multiple contributory factors.
A national survey conducted in England in 2013 and 2014 of over 6,000 adults confirmed strong associations between drinking and smoking, and alcohol use and being overweight and generally leading unhealthy lifestyles. It concluded that since individuals who exhibit health challenging behaviours are more likely to reside in deprived communities, higher rates of smoking, poor diet and being overweight are likely to amplify the harmful effects of alcohol.6 This somewhat follows the sadly, now ubiquitous social gradient in health observed in deprived regions – the lower a person’s social position, the worse his or her health.7 In fact research has shown that disadvantaged social groups have greater alcohol-attributable harms compared with individuals from advantaged areas for given levels of alcohol consumption – irrespective of different drinking patterns, obesity, and smoking status at the individual level.8
Poorer communities boast higher levels of abstainers but also higher levels of ‘heavy drinking’. A recent analysis of six years of national survey data analysed consumption patterns across socioeconomic groups in over 51,000 adults, in which alcohol consumption was measured against indicators such as household income, education, occupation, and neighbourhood deprivation. The study concluded that lower socio-economic groups are most likely to consume both under and significantly over recommended guidelines i.e., to exhibit higher levels of ‘heavy drinking’. These heavy drinkers are more likely to experience higher rates of unemployment, mental health issues, low resilience and other adverse life events – further reinforcing the social gradient and poorer health outcomes in disadvantaged communities.9
Alcohol availability is a significant contributor to the paradox. A 2015 analysis of tobacco and alcohol retail outlets in Scotland found that the most deprived areas and neighbourhoods had the highest densities of both tobacco and alcohol retail outlets. In contrast, the least deprived areas had the lowest density of tobacco and alcohol outlets.10
Policy
It is critical that the relationship between drivers for health inequalities, and alcohol consumption are considered and acknowledged by policy makers so that interventions and services may be designed and directed appropriately for the most vulnerable in society.
It is undisputed that those individuals with the highest issues with alcohol are most sensitive to price, and this has directed recent policy towards the issue of cost. Minimum unit pricing is probably the single most effective policy intervention for alcohol and its introduction in Scotland in 2018 and more latterly in Wales in 2020 has been supported strongly by authoritative voices in the alcohol and health space. The minimum unit price sets the floor price at which an alcoholic drinks may be sold – it is yet to be introduced in England.11
C3 Collaborating for Health
At C3 Collaborating for Health (C3), we seek to prevent non-communicable diseases, which so frequently co-exist with harmful alcohol consumption, by promoting the behaviour changes: improving diet and addressing alcohol consumption; increasing physical activity and stopping smoking. C3’s community engagement programme partners with local communities to identify barriers to good health such as high densities of unhealthy food outlets and lack of space for physical activity, and we use a community’s existing strengths to overcome these barriers. The aim is to make the healthy option the easy option for all.
C3 is currently working with seven communities in the North of France and the South of England via an EU-funded project ASPIRE (Adding to Social capital and individual Potential In disadvantaged REgions). This multi-partner project aims to address the complex issues of obesity and unemployment, which frequently co-exist with smoking and higher levels of alcohol consumption.
References
- Hammer JH, Parent MC, Spiker DA, World Health Organization. Global Status Report on Alcohol and Health 2018. Vol 65.; 2018. doi:10.1037/cou0000248
- Griswold MG, Fullman N, Hawley C, et al. Alcohol use and burden for 195 countries and territories, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2018;392(10152):1015-1035. doi:10.1016/S0140-6736(18)31310-2
- World Health Organization. Alcohol and Inequities.; 2014. http://www.euro.who.int/__data/assets/pdf_file/0003/247629/Alcohol-and-Inequities.pdf.
- Alcohol Change UK. Alcohol and inequalities. https://alcoholchange.org.uk/policy/policy-insights/alcohol-and-inequalities. Accessed November 14, 2021.
- Giles L. RM. Monitoring and Evaluating Scotland’s Alcohol Strategy: Monitoring Report 2017.; 2017. http://www.healthscotland.scot/media/1449/mesas-final-report_english1.pdf.
- 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. doi:10.1186/s12889-016-2766-x
- Marmot M, Bell R. Fair Society, Healthy Lives (Full Report). Vol 126.; 2012. doi:10.1016/j.puhe.2012.05.014
- Katikireddi SV, Whitley E, Lewsey J, Gray L, Leyland AH. Socioeconomic status as an effect modifier of alcohol consumption and harm: analysis of linked cohort data. Lancet Public Heal. 2017;2(6):e267-e276. doi:10.1016/S2468-2667(17)30078-6
- 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. doi:10.1186/s12889-016-3265-9
- Shortt NK, Tisch C, Pearce J, et al. A cross-sectional analysis of the relationship between tobacco and alcohol outlet density and neighbourhood deprivation. 2015:1-9. doi:10.1186/s12889-015-2321-1
- Alcohol Focus Scotland. Minimum pricing
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