Time to Promote the Awareness of Unhealthy Alcohol Use Among Women

Since the coronavirus disease 2019 (COVID-19) outbreak in March 2020, alcohol consumption has sharply and continuously increased in the United States, ^{1 –9} particularly among women. ^1,7,9 This is of concern, since before the pandemic, the prevalence of alcohol use in women was already rising. A meta-analysis of six national surveys shows that although the prevalence of alcohol use in men remained unchanged, alcohol use significantly increased in women by 6% over the past decade. ¹⁰ Results from the 2020 National Alcohol Survey found that 69% of female U.S. adults had a weekly consumption of at least one drink, ¹¹ such as a can of beer (12 oz ≥ ∼355 mL), a glass of table wine (5 oz ≥ ∼148 mL), a shot of 80-proof spirits (1.5 oz ≥ ∼44 mL), or 8–9 oz ≥ ∼250 mL of malt liquor. ¹²

Data from Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2017–2018, show that ∼20% of U.S. women aged 18–44 years old reported excessive alcohol use including binge drinking (i.e., having ≥4 drinks on one occasion) and heavy drinking (i.e., having ≥8 drinks per week). ¹³ During the pandemic, multiple reports indicate that unhealthy alcohol use and drinking above recommended limits ¹⁴ were greater in women than in men. ¹

Increases in alcohol use among women are associated with an increased burden on the health care system. Data from the Nationwide Emergency Department Sample show that the rate of emergency department visits related to alcohol significantly increased by 56% in women from 2006 to 2014, with a larger annual increase than in men. ¹⁵ Using U.S. mortality data from the National Center for Health Statistics, White et al. found that alcohol-related death rate among women increased by 2.1% per year from 1999 to 2010, and increased further more by 5.2% per year from 2010 to 2017. ¹⁶ Although the majority of alcohol-related deaths occur in men, the annual increase in death rates is higher in women than in men. ¹⁶ However, compared with those in men, the effects of alcohol use on health-related outcomes are understudied in women.

Although light-to-moderate alcohol consumption may not be overtly harmful to health, excessive alcohol use is associated with several adverse health outcomes in women. ¹⁷ Chronic excessive alcohol use is associated with the development of alcohol use disorder, and an increased risk of mental disorders, infectious diseases, breast cancer, and cardiovascular diseases in women. ^17,18 There is an alarming trend in the increased prevalence of alcohol-related liver disease ¹⁹ that parallels the increase in alcohol consumption in women. ²⁰ Recently, Wood et al. conducted a combined analysis of 599,912 current drinkers from 83 prospective studies and they found that in men and women, alcohol consumption higher than 100 g per week (∼7 drinks) was associated with a higher risk of all-cause mortality. ²¹

More than likely, the reasons for the increase and change in women's drinking intensity and patterns are multifactorial but may relate to drinking motives that may include social, coping, enhancement, and conformity. Compared with men, women are more likely to drink alcohol to cope with psychological distress, such as anxiety, stress, and depression. During the pandemic, Rodriguez et al. found that COVID-19–related psychological distress was associated with a higher amount of alcohol use and the association was more pronounced in women than in men. ⁷ To cope with psychological distress due to social isolation and/or the presence of children at home during the pandemic, ⁷ women may tend to increase their alcohol use. Other reasons for increased alcohol use may be related to the stay-at-home orders, which might create more free time and opportunities for drinking or conversely as already noted create more stress due to social isolation.

Home drinking has become common during the pandemic, as evident by the alcoholic beverage sales between March to September in 2020 versus the same time period in the previous year: Although there was a 27% decrease in food and drinking place retail sales, the sales in beer, wine, and liquor stores increased by 20%. ² Misperceptions about COVID-19 may also lead to an increase in alcohol consumption. In Iran, >700 people died of pure alcohol or toxic methanol consumption, related to the belief that drinking alcohol could cure COVID-19. ²²

Despite the increasing alcohol consumption and rate of excessive alcohol use among women, it is commonly assumed that women do not drink heavily. In addition, women are less likely than men to be screened for at-risk drinking and alcohol use disorder by health care providers ²³ and less likely to be advised/educated about the risk of excessive alcohol use. In fact, findings from studies in Europe suggest that a high level of education was associated with an increase in alcohol use during the COVID-19 pandemic. ^24,25

Our group conducted an online cross-sectional survey between May 27, 2020, and June 26, 2020, in women with a professional or postgraduate degree (n = 656, ∼82% nonsmokers), approximately half of the women reported an increase in alcohol use after the COVID-19 outbreak, to a total weekly alcohol consumption of 8 drinks (or 113 g of pure alcohol) on average. We also found that the prevalence of binge drinking over the past 30 days (51%) was higher than before the pandemic (22%). ²⁶ Perhaps alcohol consumption is perceived to cause less harm compared with other substance use, such as tobacco and cannabis, and is likely selected as a coping strategy in women. Altogether, these findings highlight the need for health providers to discuss alcohol use with women.

As people have gradually adapted and developed new daily routines and lifestyle behaviors through the COVID-19 pandemic, the emergence of the SARS-CoV-2 variants, such as Delta and Omicron may intensify these behavioral changes and alcohol consumption may continue to rise among women. It is time to promote the awareness of unhealthy alcohol use among women and the continued monitoring of alcohol use and alcohol education. The current Dietary Guidelines for Americans recommend that individuals should not initiate drinking for any reason, and if alcohol is consumed only by adults of legal drinking age and drinking in moderation, that is one drink or less per day for women. ¹²