BACKGROUND: There are substantial inequalities in alcohol-related mortality related to individual-level education, income, and employment status, but less is known about the association between alcohol-related mortality and the geographic characteristics of an area. This systematic review aims to explore whether area-level features, including area-level measures of socioeconomic status, are associated with alcohol-attributable mortality.

METHODS: We systematically searched Medline (Ovid), CINAHL, EMBASE, PsycINFO, Web of Science, Emerald Insight, and Epistemonikos databases (2004 - 2024), supplemented with searches of grey literature, for primary quantitative studies conducted in high-income countries. Eligible studies examined associations between alcohol-attributable morality and one or more geographic characteristic. Studies were quality appraised using the Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies, the Critical Appraisal Skills Programme for cohort studies, and the National Heart, Lung and Blood Institute checklist was adapted for assessing ecological studies. The findings were synthesised narratively. [PROSPERO ID CRD42024499928.]

RESULTS: The searches identified 73 eligible studies covering mortality from a range of alcohol-attributable conditions, including chronic alcohol-specific conditions (e.g. alcohol-related liver disease) and alcohol-related incidents (e.g. road traffic collisions, suicides). Study quality was found to be good in most cases. Urban-rural location was the most common exposure and alcohol-specific mortality was the most common outcome measured in the included studies. Of the 34 studies examining area-level socioeconomic deprivation, all studies found a positive association between deprived areas and alcohol-attributable mortality. Of the 49 studies that examined urban-rural location, 26 (53.1%) found a positive association between rural location and alcohol-attributable mortality. Fourteen studies (28.6%) found urban location significant. Rural locations were particularly associated with alcohol-related road traffic collisions and suicides.

CONCLUSIONS: Greater area-level deprivation and rurality are associated with higher rates of alcohol-related mortality.