The association between macro-level structural discrimination and alcohol outcomes: A systematic review

Alcohol consumption is a major risk factor for death and disability, disproportionately harming disadvantaged groups. While a positive association between interpersonal discrimination and alcohol use is established, structural discrimination's impact remains unclear. We conducted a systematic review of the association between macro-level structural discrimination and alcohol consumption or related health outcomes. We searched four databases and grey literature, identifying 25 eligible studies, which considered racism (n = 11), sexism (n = 7), heterosexism (n = 4), and intersectional discrimination (n = 3). Most considered alcohol consumption (n = 17); fewer addressed harm (n = 4) or both (n = 4). The majority were US-based (n = 21), with four making cross-country comparisons. Associations varied by discrimination type, exposure measurement, alcohol outcome, and sociodemographic factors, though differential effects by sociodemographic factors remain understudied. Most structural racism studies considered segregation as the exposure, but findings were inconsistent, even when grouped by outcome. Emerging evidence suggests increased race-based poverty ratios and incarceration gaps are associated with higher consumption and harm, especially for Black and Hispanic populations. Studies of structural sexism often used composite measures, like state-level gender inequality indices. Evidence suggests that as gender equality increases, women are more likely to drink, while greater structural sexism may be linked to higher rates of risky drinking and alcohol-related mortality. Findings on heavy episodic drinking and drinking frequency were mixed, while associations with volume and quantity were mostly non-significant. The limited available evidence suggests structural heterosexism may be positively associated with high intensity drinking and alcohol use disorders among sexually minoritized groups. The simultaneous impact of multiple forms of structural discrimination remains underexplored. Advancing this field requires consensus on how to operationalize structural discrimination within alcohol studies and greater adoption of intersectional and longitudinal approaches.