New research from a collaboration including Bangor University, Liverpool John Moores University and Alcohol Research UK explains why people in deprived communities have higher levels of alcohol-related ill health than people in non-deprived communities, despite drinking the same amounts of alcohol -- the alcohol harm paradox.

The study, conducted in England and published in the open access journal BMC Public Health, found that people who are heavier drinkers and live in low-income communities are more likely to combine such drinking with other health damaging behaviors than people in more affluent communities. These combinations do not just add to the dangers from alcohol consumption but effectively multiply the risks of ill health.

The researchers found that people living in deprived areas who drank at levels consistent with increased risks to health -- men: more than 21 UK units per week, women: more than 14 units per week,- were nearly 11 times more likely than people living in non-deprived areas to combine drinking with smoking, excess weight, poor diet and little exercise. In combination, these behaviors multiply the risk of alcohol-related conditions.

For those drinkers at increased risk, 66.9% of those living in non-deprived areas were found to have at least one other health risk behavior, compared with 83.2% of those living in deprived areas. Mark Bellis, one of the researchers from Bangor University, said: "About 9% of increased risk drinkers surveyed in poorer communities also smoked, were overweight and had unhealthy lifestyles. Together these combinations can create enormous stresses on people's bodies, overwhelming their ability to limit the health harms caused by alcohol. In affluent areas less than 1% of people drinking at increased risk levels also reported all three other health risks."

Drinkers living in deprived areas were found to be more likely to drink spirits and beer than wine and to be more likely to binge drink than those in non-deprived areas.

Mark Bellis said: "Drinkers in more deprived communities were more likely to drink their weekly alcohol in fewer but heavier drinking sessions. Such behaviors can increase risks of injury and heart disease compared to people who drink the same total amount of alcohol but over more occasions."

The researchers conducted a telephone survey in England between May 2013 and April 2014. A cohort of 6,015 randomly selected adults aged 18 years and over provided information on their age, sex and ethnicity, as well as their current and past alcohol consumption. Respondents were identified as living in non-deprived or deprived areas based on the IMD (Index of Multiple Deprivation) of the area they lived in. IMD combines indicators like income, unemployment, health education and crime to provide a single measure of deprivation for a given geographical area.

Interactions between alcohol consumption and other health risk behaviors were explored through questions about smoking, diet and exercise, current drinking patterns (bingeing and types of alcohol consumed), and drinking history.

The response rate to the survey was 23.3%. Although this is in line with typical response rates for telephone surveys, bias related to the low response rate could affect study results, as could recall errors in people's responses to questions about their drinking history. Further research may be needed to look more closely at individual deprivation in addition to deprivation by area.

Even though no causal relationship between deprivation and either combined health challenges or current and historic binge drinking was identified in this study, the researchers suggest that harms from alcohol consumption should not be viewed in isolation. Better understanding of the implications of the alcohol harm paradox is needed to develop and target appropriate information on drinking both in developed and developing countries. The promotion of alcohol is being scaled up globally and a better understanding of how alcohol affects those living in poverty may help prevent developing even greater national and global health inequalities, according to the researchers.

James Nicholls, from Alcohol Research UK, said: "This research highlights the importance of wider social, economic and behavioural factors in understanding alcohol related harm. It suggests that health risks from alcohol are much greater when combined with smoking, poor diet and low levels of physical activity. This information is important for individual lifestyle choices, but also for tackling the broader problem of health inequalities. Better awareness of how broader health behaviours exacerbate alcohol-related health harms is invaluable, but addressing the 'harm paradox' also means targeting the structural issues that can make healthier choices harder for people in deprived communities."