Drinking and deprivation in England
Comparing alcohol use, attitudes and support across levels of deprivation.
Background
Alcohol-related harm remains a significant public health issue, but its impact is not felt equally among the population. Evidence consistently shows that individuals living in the most deprived areas of the country experience greater alcohol-related harm compared to those living in the least deprived areas—despite drinking either the same amount of alcohol or less. This phenomenon is known as the ‘Alcohol harm paradox’.1
In 2023, individuals living in the most deprived areas of England experienced substantially higher alcohol-related harm, including hospital admissions and deaths. Specifically, the alcohol-specific mortality rate in these areas was 2.13 times higher than in the least deprived areas (20.9 per 100,000 population vs. 9.8 per 100,000 population).2 This discrepancy extends to, not only physical health outcomes, but also self-reported harms of alcohol use.3
What is deprivation?
Deprivation is measured through the Index of Multiple Deprivation4 (IMD), which ranks small geographical areas (neighbourhoods) in England based on various social and economic factors such as income, education, employment, housing quality, and access to services. To make comparisons easier, these areas are divided into ten equal groups, called deciles, ranging from Decile 1 (the most deprived 10% of areas) to Decile 10 (the least deprived 10%). This allows researchers to assess differences in health and wellbeing across the socioeconomic spectrum.
While similar deprivation measures exist in other parts of the UK, differences in methodology make direct comparisons challenging. Our report focuses on England due to the larger sample size available from the 2023 Drinkaware Monitor.
Several explanations have been proposed for this paradox5, including underreporting of differences in drinking patterns (e.g., binge drinking), and behavioural factors, such as co-occurring negative health behaviours (such as smoking, poor diet etc.), which can amplify harm.6 However, research indicates that risk behaviours only partially explain the disparity.7 The remaining variance is likely driven by wider determinants of health, such as access to healthcare, housing conditions, job insecurity, and social support.
What did we do?
The goal of this research was to examine patterns of alcohol use, attitudes, and support across different deprivation levels in England. This involved a comparison between individuals living in the most deprived areas (deciles 1-2) and the least deprived areas (deciles 9-10).
Key Findings
Drinking patterns and harm
- People living in the most deprived areas are less likely to drink alcohol, than those living in the least deprived areas. Yet, people living in more deprived areas are more likely to drink larger amounts of alcohol on a typical drinking day (7+ units), and they are also more likely to engage in binge drinking.
- Individuals living in the most deprived areas are more likely to be categorised as high-risk or possibly dependent drinkers based on the Alcohol Use Disorders and Identification Tool.
- People living in deprived areas are more likely to drink for coping reasons, such as when they are feeling depressed or nervous or to forget about their problems.
Attitudes toward alcohol
- Despite higher levels of risky drinking, people living in deprived areas are more likely to view their relationship with alcohol as healthy. They are also less likely to see getting drunk as problematic, as long as it does not occur frequently or negatively impact others.
- Drinking among those living in more deprived areas is more likely to lead to negative or risky behaviours, such as mood swings and arguments, particularly when people drink to excess.
- People living in the most deprived areas tend to be less aware of the potential harms of drinking at risky levels and are less likely to link drinking with certain health conditions.
Concern and support
- Drinkers living in the most deprived areas are more likely to have had concern expressed about their drinking, and those living in the most deprived areas are more likely to be concerned about someone else's drinking.
- Those living in the most deprived areas are less likely to report that they have had an alcohol screening test and are less likely to feel they would seek support for alcohol-related issues. Yet, they are more likely to have accessed services - especially for themselves.
Such findings are even stronger when we look at just those who live in the 10% most deprived areas.
Alcohol harm beyond drinking patterns and attitudes
While highlighting differences in behaviours, attitudes and awareness is important, the alcohol harm paradox will not be addressed focusing on downstream initiatives alone. Alcohol harm is influenced by a complex interplay of factors beyond drinking behaviour and attitudes. Wider social and economic inequalities play a key role in why those living in the most deprived areas experience worse alcohol-related harm, despite not always drinking more.
References
[1] Bloomfield, K. (2020). Understanding the alcohol-harm paradox: what next?. The Lancet Public Health, 5(6), e300-e301.
[2] Department of Health & Social Care. Alcohol Profile. Alcohol-specific mortality.
[3] Rossow, I., & Bye, E. K. (2024). The alcohol harm paradox: is it valid for self-reported alcohol harms and does hazardous drinking pattern matter?. BMC Public Health, 24(1), 3053.
[4] Ministry of Housing, Communities & Local Government. (2019, September 26). English indices of deprivation 2019.
[5] Boyd, J., Sexton, O., Angus, C., Meier, P., Purshouse, R. C., & Holmes, J. (2022). Causal mechanisms proposed for the alcohol harm paradox—a systematic review. Addiction, 117(1), 33-56.
[6] Bellis, M. A., Hughes, K., Nicholls, J., Sheron, N., Gilmore, I., & Jones, L. (2016). The alcohol harm paradox: using a national survey to explore how alcohol may disproportionately impact health in deprived individuals. BMC public health, 16, 1-10.
[7] Probst, C., Kilian, C., Sanchez, S., Lange, S., & Rehm, J. (2020). The role of alcohol use and drinking patterns in socioeconomic inequalities in mortality: a systematic review. The Lancet Public Health, 5(6), e324-e332
