• Public health concerns
• Targeted interventions for women
• Conclusions
• Policy options
• References

In most societies, women have been less likely than men to drink alcohol, to consume it heavily, and to experience adverse effects. In recent years, however, there has been an increase in the number of women who drink, as well as in the quantities of alcohol they consume. A rise in heavy drinking particularly among young women has been reported from a number of countries (e.g., Bloomfield, Grittner, Kramer, & Gmel, 2006; Hibell et al., 2000, 2004; Higuchi, Suzuki, Matsushita, & Osaki, 2004; McPherson, Casswell, & Pledger, 2004; Office for National Statistics, 2004; Plant, 1997; Plant, 2004; Plant & Plant, 2001; Plant, Plant, & Mason, 2002; Wilsnack & Wilsnack, 1997). Therefore, from a public health perspective, it is imperative to focus on women’s drinking patterns and to ensure that their needs are met with regard to prevention and harm minimization.

Public health implications

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For women—as for men—the relationship between alcohol consumption and outcomes, both positive and negative, is influenced by patterns of drinking, as well as by cultural attitudes to alcohol consumption (Grant & Litvak, 1998; Hibell et al., 2000, 2004; International Center for Alcohol Policies, 2004; World Health Organization, 2004). In addition, several gender-specific factors contribute to women’s relationship with alcohol (Nolen-Hoeksema, 2004; Plant, 2002; Wilsnack & Wilsnack, 1997).

As a first step, it is important to understand that alcohol’s effects are different for women than they are for men (Lieber, 1997; Mumenthaler, Taylor, O'Hara, & Yesavage, 1999; Nolen-Hoeksema, 2004). In general, alcohol affects women at lower doses than it does men. This is due in part to the fact that women are generally smaller and that their bodies contain less water and more fat, allowing the concentration of ethanol to rise more quickly. There are also differences between men and women in the enzymatic processes that break down ethanol and eliminate it from the body. As a result, it generally takes less alcohol to cause physical harm in women than it does in men (ANNEX 1: The Basics about Alcohol; Lieber, 1997; Nolen-Hoeksema, 2004).

With these differences in mind, there is much evidence regarding the benefits and harms of alcohol consumption for women. In general, as is the case for men, there is little evidence that low to moderate consumption of alcohol causes harm in most women; similarly, patterns of heavy drinking, both episodic and chronic, are associated with a number of adverse outcomes.

A range of health benefits associated with low to moderate alcohol consumption has been described in women:

• Particularly for postmenopausal women, there is a link with reduced risk for coronary heart disease, CHD (Baer et al., 2002; Camargo, 1999; Fuchs et al., 1995; Grobbee, Rimm, Keil, & Renaud, 1999).
• Even in pre-menopausal women, for whom CHD is less of a concern, there may be benefits related to blood cholesterol levels—i.e., reduction of low-density lipoprotein cholesterol, LDL, often referred to as “bad cholesterol,” and increase in high-density lipoprotein, HDL, also known as “good cholesterol” (Koppes, Twisk, Snel, Van Mechelen, & Kemper, 2000; Sillanaukee, Koivula, Jokela, Pitkajarvi, & Seppa, 2000).
• Research evidence suggests that moderate alcohol consumption may have a protective effect against Type 2 diabetes (de Vegt et al., 2002; Kao, Brancati, Boland, Watson, & Puddey, 1998; Wannamethee, Camargo, Manson, Willett, & Rimm, 2003).
• For older women, there may also be beneficial effects regarding the progression of osteoporosis and the severity of bone fracture (Charles, Laitinen, & Kardinaal, 1999; Diaz, O'Neill, Silman, & European Vertebral Osteoporosis Study Group, 1997; Felson, Zhang, Hannan, Kannel, & Kiel, 1995; Rapuri, Gallagher, Balhorn, & Ryschon, 2000; Smeets-Goevaers et al., 1998; Williams, Cherkas, Spector, & MacGregor, 2005).

On the other hand, harmful drinking patterns—including both chronic and episodic heavy drinking—have effects on the health of women, as they do on men.

• Heavy chronic and episodic drinking has been linked with an increase in risk for CHD and certain types of stroke (Grobbee et al., 1999; Klatsky, 1999, 2001).
• Hepatic effects, including liver cirrhosis, have been well described for many who abuse alcohol (e.g., Lieber, 2003; Mann, Smart, & Govoni, 2003; Rodés, Salaspuro, & Sorensen, 1999).
• Heavy drinking appears to increase risk for diabetes (e.g., de Vegt et al., 2002).

Certain health outcomes apply specifically to women:

• Alcohol consumption, even at low doses, may increase the risk for breast cancer in women, particularly if there is a family history of the disease (Aronson, 2003; McPherson, Cavallo, & Rubin, 1999; Singletary & Gapstur, 2001; Smith-Warner et al., 1998).
• Hormone/estrogen replacement therapy among postmenopausal women may increase risk for harm from alcohol consumption (Chen et al., 2002; Ginsburg, 1999).
• Heavy drinking may also be a contributing cause in female infertility (Eggert, Theobald, & Engfeldt, 2004; Olsen, Bolumar, Boldsen, & Bisanti, 1997; Tolstrup et al., 2003).
• Certain maternal drinking patterns during pregnancy may present a risk for fetal alcohol syndrome and related disorders in offspring and increase the risk for spontaneous abortions (MODULE 10: Drinking and Pregnancy; e.g., Plant, Abel, & Guerri, 1999).
• Women who are nursing may transfer alcohol to their child through breast milk, which might adversely affect the infant’s sleep and development (De Araujo Burgos, Bion, & Campos, 2004; Mennella, 2001).
• A strong association between affective and anxiety disorders and problem drinking has been described in women, often increasing with age (Allan, 1995; Chander & McCaul, 2003; Pulkkinen & Pitkanen, 1994).
• Heavy and problematic drinking in women has also been associated with eating disorders and other behaviors such as compulsive shopping (Plant, 1997; Plant, Miller, & Plant, 2005).
• Certain patterns of drinking and situations increase the vulnerability of women and the risk for harm from sexual assault and violence (MODULE 7: Drinking and Violence; e.g., Kaufman Kantor & Asdigian, 1997; Mohler-Kuo, Dowdall, Koss, & Wechsler, 2004).

Targeted interventions for women

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It is evident that some drinking patterns are linked with problems and harm among women. Many of these problems are specific to women and may be closely related to their social roles, status, and expectancies around alcohol. Harm reduction approaches to policy and prevention offer a useful means of addressing alcohol consumption in women and reducing the potential for harm.

However, what approaches may be appropriate depends to a large degree on priorities and cultural sensitivities in different countries. Thus far, the data on women’s drinking and related problems are still inadequate, although several large-scale comparative studies are collecting information across borders and cultures (e.g., Currie et al., 2004; Hibell et al., 2000, 2004; Norström, 2002; Wilsnack & Wilsnack, 2002). Similarly, the availability of services specifically tailored to women is not available in many communities. In order for harm reduction to be effectively implemented, a change in a number of cultural attitudes regarding women’s drinking will be necessary.

The key to reducing harm associated with certain drinking patterns among women is to evaluate available strategies and to sustain those that are effective. It is emphasized that successful alcohol policy should work within a climate of social and political acceptability. Such climate may sometimes need to be influenced by highlighting the value and relevance of research findings so that policy-makers are well-informed.

Harm reduction strategies should also take into account that different approaches may be needed for women at different stages of their lives:

• Among younger women, harm minimization should target the reduction of heavy periodic (or “binge”) drinking. As a result, the possibility of alcohol server training to discourage heavy consumption during drinking sessions may be a useful approach. Similarly, interventions that address alcohol intake during pregnancy may be needed.
• Among middle-life women, drinking alcohol is a common means of stress reduction. It would be useful, therefore, to increase these women’s awareness of the potential risks involved and to help them monitor the balance between work and leisure, including exercise and health.
• Older women may benefit from regular screening for their drinking habits and from raising awareness about alcohol’s possible interaction with medication.

Additional specific areas exist in which alcohol consumption among women can benefit from targeted harm reduction approaches.

Information

For policy purposes, women are often considered an “at-risk population,” particularly vulnerable to potential harm from alcohol consumption patterns. As a result, many official guidelines issued by governments and other bodies in countries around the world offer information about alcohol that is specifically tailored to women (MODULE 19: Drinking Guidelines).

In many countries, the recommendations for women’s drinking are lower than they are for men; others do not differentiate between the sexes (see Table 9.1 below; International Center for Alcohol Policies, 2003). Some official guidelines also offer advice about drinking during pregnancy. Where such guidelines exist, they usually recommend either complete abstinence or very low or moderate drinking levels (MODULE 10: Drinking and Pregnancy; Policy Table: International Drinking Guidelines; International Center for Alcohol Policies, 1999).

Information for women about drinking patterns and potential benefits and harms is also imparted through various health and other workers. These include physicians and nurses, other caregivers, and social workers. An important prerequisite for this is that these individuals should have the necessary training to provide adequate information. They should be aware of the issues that specifically apply to women and be able to assist with problems that may arise, provide advice around drinking patterns, and offer treatment, where necessary and appropriate.

Personal safety

There is evidence that some crimes, particularly violent crimes, may be associated with heavy drinking, especially in and around places where people consume alcohol (Plant, Plant, & Thornton, 2002). While most of the victims of assault are males, the issue of personal safety is a serious one for women (Abbey, Mcauslan, & Ross, 1998; Kaufman Kantor & Asdigian, 1997). One recent topic of concern is the so-called “date rape” drugs, including Rohyphnol, Ketamine Hydrochloride, and Gamma Hydroxy Butyrate (GHB), used to spike drinks. While several products reputed to be able to detect the presence of these substances are available, the best approach to reduce the potential for harm relies on personal skills, including awareness among women about their own drinking behavior and that of their friends.

Table 9.1 International Drinking Guidelines: Advice for Women

Sexual behavior

Rich folklore and mythology exist in many societies about the link between drinking and sexual behavior. Much of this concerns the “disinhibiting” effects of alcohol (Room & Collins, 1983). A number of studies have concluded that heavy drinkers are more likely than others to engage in sexual risk taking (Cooper, 2002; Leigh & Schafer, 1993; Leigh, Temple, & Trocki, 1994). Even so, this appears to be part of a general tendency to take risks and may not be directly influenced by alcohol consumption on specific occasions (Chandra, Krishna, Benegal, & Ramakrishna, 2003; Justus, Finn, & Steinmetz, 2000). Harm reduction measures around sexual activity can be encouraged to keep women safe.

Pregnancy

The subject of drinking during pregnancy is addressed in MODULE 10: Drinking and Pregnancy. There is currently no consensus on a threshold level of maternal drinking below which the risk to the fetus is negligible. As a result, abstinence or low levels of alcohol consumption are generally recommended during pregnancy by most official guidelines (International Center for Alcohol Policies, 2000). Clearly, it is important to provide accurate advice about dangers of heavy drinking during pregnancy.

Screening

As mentioned earlier, regular screening for alcohol problems and other potential contributors to health and social outcomes may be advisable for older women. However, there is also evidence that certain characteristics in girls and young women may be good predictors of future alcohol problems (Cyr & McGarry, 2002). In young girls, such predictors include high levels of anxiety and poor performance in school. An association has also been made between women with eating disorders and the later development of alcohol problems (see MODULE 18: Early Identification and Brief Intervention).

Conclusions

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Most women who drink do so moderately and generally do not suffer adverse effects. The greatest health and social risks are associated with heavier drinking, either on an occasional or a regular basis. However, while many relationships between drinking patterns and outcomes apply equally to men and women, there are certain areas in which women may be particularly susceptible but in which the potential for harm can be reduced.

Balanced policy approaches should take greater account of women’s drinking patterns, needs, and outcomes. As a first step, a greater effort to collect comprehensive and reliable cross-cultural data is needed. In addition, services and guidance tailored to women are a largely neglected area that would benefit from increased attention.

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