Why alcohol policies miss those at the highest risk from drinking

People living in the most advantaged areas of Australia tend to drink more alcohol. But people who live in the least advantaged areas suffer the most alcohol-related harms, such as dying from alcohol-related disease or from alcohol-related injuries.

This puzzling phenomenon is known as the “alcohol harm paradox” And knowing what’s behind it has real-world implications.

It can help explain why educational campaigns to drink less alcohol, such as the “sober curious” movement, don’t always reach those most at risk of harm.

It can also help us design better policies to prevent alcohol-related harms – including some policies unrelated to alcohol.

So, rich people drink more?

In 2022, for example, about 31% of Australians living in the most advantaged neighbourhoods exceeded national guidelines for risky drinking in the past year. That’s compared with about 22% in the least advantaged neighbourhoods.

However, people living in more disadvantaged areas have more alcohol-related problems than people with living in more advantaged areas.

For instance, research from the United Kingdom shows those living in the most disadvantaged neighbourhoods are about 2.2 times more likely to die from alcohol problems than those in the least disadvantaged neighbourhoods.

Why is this happening?

Researchers have tried to explain why this is happening. Many have pointed to behavioural factors – choices that people make and actions they take.

For instance, researchers have questioned whether the type of alcohol, patterns of heavy drinking, or where people drink, might explain why people in disadvantaged areas suffer more from alcohol-related harms. But many studies show these factors do not explain it.

Could the combination of drinking with smoking and/or illicit drugs be a factor? Could it be linked to obesity, which we know is more common in lower socioeconomic groups? Research shows this is not the explanation either.

This focus on people’s behaviour can have unintended consequences. Yes, it can lead to policies that try to get people to change their alcohol use or health behaviour, which can work for some groups. But such policies can exclude those most at risk of harm.

Why educational campaigns don’t always work

One common policy to try to change people’s behaviour is an educational campaign – the type we’d see on TV, online or on social media – to promote a healthy relationship with alcohol.

People living in more advantaged neighbourhoods, or with higher incomes, have greater access to material and social resources. They can draw on these resources – including organisations or individuals that can support them – to avoid risks, reduce the consequences of health and social problems, and take treatment to improve their health and wellbeing.

But people in lower socioeconomic groups may not have equal access to public health messages (for instance, through less access to good quality health care), understand these messages in the same way, or have the same resources and capacities to change their behaviour.

So educational campaigns can actually increase health inequalities.

Are you ‘sober curious’?

I was involved in an Australian study that looked at being “sober curious”, a social movement that emphasises being curious about living life or attending events without drinking alcohol. We explored individuals of different socioeconomic status and whether they were prepared to engage with being sober curious.

Participants of higher socioeconomic status found notions of being sober curious resonant, useful and fitted their lifestyles. But participants of lower socioeconomic status found it “for someone else” and didn’t identify with the concept.

In other words, the group most at risk of alcohol-related harms would have been least likely to take part.

Other interventions that may worsen alcohol-related inequalities also focus on an individual changing their behaviour. These include national guidelines on how much alcohol is safe to drink, and bans on drinking in public spaces that marginalise disadvantaged communities. These are policies that many Australians and policy makers think useful or necessary.

So to reduce alcohol-related inequality we need to fundamentally rethink the types of policies to reduce its harms.

So how can we design better policies?

We need to shift the focus from individual behavioural factors to see how broader social and structural conditions affect people’s health, and design policies to address these.

We need national policies that reduce drinking across the population. These include policies to reduce the availability of alcohol, especially avoiding clustering alcohol outlets in disadvantaged areas.

Another proven effective policy measure involves increasing the price of alcohol so that it cannot be sold under a certain “floor price”. This reduces the availability of very cheap alcohol.

However, policies that address the alcohol harm paradox most successfully may not be relevant to alcohol, but those that focus on reducing health inequality more broadly. These might include more equitable access to housing and better workplace policies as well as more equitable access to health care.

Better social conditions for all Australians would lead to improvements in mental health and wellbeing, and this could reduce alcohol-related harms across demographics. With more research, which I’m conducting, we could find out, and make some headway in reducing alcohol-related inequality in Australia.

If this article raises issues for you or someone you know, call the National Alcohol and Other Drug Hotline on 1800 250 015. Other support is also available.