A new study of drinking in Scotland published in the medical journal The Lancet Public Health takes a fresh look at an old subject. The so-called ‘alcohol harm paradox’ basically states that people living in socially deprived areas are more likely to suffer alcohol-related harms than those living in more affluent circumstances – even though the more affluent actually drink more alcohol. Why anyone with the smallest understanding of the complexities of health inequalities or drinking cultures should find this paradoxical I really don’t know, but apparently, some do.
So, what added value does yet another trot round this well-worn path give us? Well, temperance organisations the Institute for Alcohol Studies (IAS) and the UK Alcohol Health alliance (AHA) both like this piece of research because it concludes that targeting policies and intervention at heavy drinkers in low socio-economic groups with a view to reducing their consumption is unlikely to be as effective as whole population measures. Yes, you guessed it, minimum unit pricing, reductions in alcohol availability and advertising and marketing.
Study co-author Dr Elise Whitley said: “Heavier drinking is associated with greater alcohol-related harm in all individuals. However, our study suggests that the harm is greater in those living in poorer areas or who have a lower income, fewer qualifications or a manual occupation.”
Responding to the study, Professor Sir Ian Gilmore, chair of the Alcohol Health Alliance, said: “The findings in this study are worrying if not altogether surprising. It is clear that the way alcohol is being sold and promoted in Scotland and elsewhere in the UK is harming some of the most vulnerable people in society.”
Now conceding, as the study does, that the poor are likely to suffer more ill-health as a result of other factors associated with poverty – lifestyle, diet, and so forth, it is something of a stretch to reach the conclusion that the alcohol harm paradox is all the fault of how Big alcohol markets its products! In the introduction to this study, the authors make this, rather telling, observation:
“Efforts to target alcohol consumption by socio-economic status are unlikely to be successful in reducing health inequalities, unless drinking cultures in the most disadvantaged populations differ systematically from societal norms. Interventions seeking to reduce consumption across the whole population are more likely to result in greater reductions in absolute health inequalities than previously thought.”
The key assumption here is that targeting alcohol consumption by socio-economic group is unlikely to be successful “unless drinking cultures in the most disadvantaged populations differ systematically from societal norms.” Societal norms? The main societal norm is moderate drinking. But we don’t have one single drinking culture in the UK, or even in Scotland, and I for one believe that differing drinking cultures are the real drivers of alcohol-related harms.
I believe that once we understand the central importance of culture to drinking behaviour then we can begin to untangle the reasons why people drink at different levels, sometimes harmfully, in different ways and for different reasons. Let’s start off with a rough-and-ready definition of culture: “Culture is what me and you get up to round here.” Put more formally, sociologists refer to “cultures of intoxication” which is an understanding that places alcohol use into a modern context - one that recognises the plurality of drinking cultures and sub-cultures; that acknowledges that in addition to alcohol a whole generation of people now find it socially acceptable to take a range of other, illegal, intoxicants as part of a night-out. And that specific cultures of intoxication drive not only the quantity people drink, but the speed at which they drink it; whether they drink with food or on an empty stomach; what else they take; and whether they drink in safe places and social surroundings or dodgy bars and late-night party-pads.
When we look at the way in which alcohol health-harms are socially distributed we can clearly see the impact of the plurality of cultures of intoxication and the simplistic nature of the whole population approach. In 2010 the North West Public Health Observatory published a series of reports that break down drinking patterns and alcohol problems into different population segments.
By using the UK Government’s Index of Multiple Deprivation, the reports showed that people living in the poorest fifth of the population are five-and-a-half times more likely to find themselves in hospital with ‘alcohol-specific mental and behavioural disorders’ than those living in the richest fifth. People living in the poorest tenth are seven-and-a-half times more likely to end up in hospital because of alcohol than those in the richest tenth. People living in social housing are eight-and-a-half times more likely to have an alcohol-related disorder than a ‘career professional’; and those classified as ‘vulnerable disadvantaged’ register 13 times more alcohol-related hospital admissions than ‘affluent families’.
Social class, prosperity or the lack of it, and a range of other social circumstances determine what your drinking culture is likely to be, and the extent to which your life revolves around a culture of intoxication. But rather than calling for policies that tackle endemic poverty, ideologically motivated academics prefer to interpret data in a way that supports their preconceived whole population measures. All roads lead to minimum pricing!