"The alcohol-harm paradox": Understanding socioeconomic inequalities in liver disease

The alcohol-harm paradox (AHP) refers to the fact that people from lower socioeconomic groups experience higher rates of alcohol-related illness despite consuming the same or even lower amounts of alcohol than their more affluent counterparts. While differences in drinking patterns and associations with other risky behaviours partially explain the paradox, they do not fully account for the disparities in morbidity and mortality across socioeconomic groups. The existence of an alcohol-harm paradox in liver disease has been demonstrated in many countries worldwide. Recently, the COVID-19 pandemic further exacerbated these differences and led to an increase in alcohol intake and alcohol-related mortality among racial and ethnic minorities in the United States. Approaches to limit alcohol sales, through introduction of minimum unit pricing or taxation, have led to reductions in alcohol-related liver disease, particularly in socioeconomically deprived areas. Disparities in access to treatment of alcohol use disorder, liver disease and liver transplantation further contribute to the AHP. This review focuses on the AHP, its impact on liver disease and the multi-level strategy that will be required to curb this phenomenon.