Describing the alcohol harm paradox: 20 years of data from Victoria, Australia

Abstract Background and aims Internationally, rates of harm from alcohol tend to be higher in lower socio‐economic groups, even while drinking is lower. This is known as the alcohol harm paradox. There are very little Australian data published on socio‐economic disparities in alcohol consumption and harm, and none that has examined changes over time. This paper aimed to describe trends in socio‐economic inequalities in key measures of alcohol consumption and alcohol‐related harm over 21 years in Victoria, Australia. Design Trend analysis of population rates of separate data on hospital, emergency department and drinking behaviour. Setting Victoria, Australia, between 2000 and 2020. Participants/cases Survey data from 37 422 respondents plus 841 792 hospital admissions and 591 824 emergency department presentations. Measurements Socio‐economic status was measured using an area‐based index based on postcode of residence, divided into quintiles. Two measures of drinking were assessed based on survey responses: annual volume of drinking and frequency of risky (50 g or more) drinking occasions. Chronic harms were measured via hospital admissions for alcohol‐related liver disease and acute harms via emergency department presentations for alcohol‐related disorders. Differences in drinking and harm rates across quintiles were assessed using negative binomial regression, with interactions to examine whether the social gradients changed over time. Findings For men, there were no statistically significant differences in either total volume of drinking or frequency of episodic risky drinking between socio‐economic quintiles. For women, volume of drinking was generally higher for those living in more advantaged neighbourhoods e.g. Incident Rate Ratio (IRR) = 1.60, 95% confidence interval (CI) = 1.32–1.95 for women in the most advantaged compared with most disadvantaged, while frequency of episodic risky drinking did not differ statistically significantly. Trends in drinking on either measure did not differ by socio‐economic status for men or women. Alcohol‐related harms were higher for people living in disadvantaged neighbourhoods for most outcomes and sub‐groups analysed. For example, male rates of alcohol‐related liver disease were nearly twice as high in the most disadvantaged quintile as in the least disadvantaged quintile (IRR = 0.54, CI = 0.50–0.58). On some measures there was evidence that the gap between socio‐economic groups had widened over time. Conclusions Despite similar or lower levels of alcohol consumption, people living in more disadvantaged socio‐economic areas of Victoria, Australia, appear to experience much higher rates of alcohol‐related harm than those in more advantaged areas, with some disparities widening over time.