Not just a “lifestyle disease”BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39520.716863.94 (Published 24 April 2008) Cite this as: BMJ 2008;336:952
Are we now seeing the undesirable consequences, for instance in drinking and smoking habits, of female emancipation? As women quite rightly seek greater opportunities for equality in the workplace and in other aspects of life, we see signs of them falling prey more and more to so called lifestyle diseases. Young women are all too commonly seen huddling outside enjoying a cigarette; and while lung cancer rates fall overall, they continue to rise in women. Women are also conspicuously heading for equality in their drinking habits. In the most recent British general household survey, 42% of men and 39% of women aged 16 to 24 years had exceeded safe recommended daily limits in the previous week, with over half of those drinking heavily or “bingeing.”1 The United Kingdom has the heaviest drinking young women in Europe, nearly 40% of whom admit to having drunk six or more units in one session in the previous week.2
Does it matter that our young women are having fun? Most get away without harm and will probably settle down. But those who do not escape harm may have their life changed fundamentally under the influence of alcohol. Most first consensual sexual experiences and unwanted pregnancies occur in this way, and the distinction between rape and sex regretted the next day can become blurred when women are drunk. Genitourinary clinics see drink as the biggest factor in unprotected sex and sexually acquired infections. Some young women will be scarred for life through drunken brawls and arguments. In Scotland about 30% of women committing violent crime are drunk.3
Of course, the victims of accidents need not be drunk themselves: alcohol is responsible for much third party or collateral damage. In England and Wales, over half of victims of violence perpetrated by a stranger judged the attacker to be under the influence of alcohol.4 This is particularly an issue in domestic violence, where again at least half of perpetrators are likely to have been drinking.4 It is remarkable how damage to the health of third parties was such a tipping point for public opinion on the issue of smoking in public places, yet alcohol is hugely more serious in this regard.
Teenage girls and young women are unlikely to be receptive to arguments about serious organ damage in years to come, and so it is important to highlight dangers that are more immediately relevant to them. It is now apparent that fetal alcohol syndrome, where babies are born with severe brain damage and a typical physical appearance, is but one end of a spectrum (fetal alcohol spectrum disorders); and less obvious behavioural disorders such as attention deficit hyperactivity disorder may result from exposure to alcohol in the womb.5 Unfortunately exposure in early pregnancy is likely to be important, and so far no safe threshold has been identified. Thus the only safe advice is for women to avoid alcohol if they seek to become pregnant—tough advice where every celebration now seems to have alcohol at its core.
Alcohol misuse remains the most important cause of death from chronic liver disease (cirrhosis), the prevalence of which has grown startlingly in women, particularly in the 35-44 year age group (sevenfold in the last three decades) but also in even younger women.6 This reflects the early age when heavy drinking starts. Particularly striking is the emergence of the syndrome of alcoholic hepatitis (not always associated with histological cirrhosis), where the patient is febrile, deeply jaundiced, and often has ascites and other features of decompensation of liver function. Histologically this can be indistinguishable from non-alcoholic fatty liver disease, and it has been suggested that alcoholic hepatitis may be a “double hit” of alcohol on top of a fatty liver, often associated with obesity, which would explain the rapid increase in the disease. Certainly the burden of harm is seen disproportionately in the most disadvantaged in society, a striking example of health inequality that remains unexplained.
What can be done to turn this tide of alcohol related health harm in young women? We know that telling them to behave better will not work. England’s national alcohol harm reduction strategy of 2004 relied heavily on voluntary partnerships with producers and retailers of drink, linked to public education and information. Sadly, these initiatives have palpably failed. This should not surprise us too much, because the best predictor of alcohol related health damage is per capita consumption, and it can hardly be in the industry’s interests to have falling sales. Hence we need to fall back on the tools that have an international evidence base: mainly price and availability.7 8 Alcoholic beverages have never been as cheap in real terms as they currently are—particularly those sold in off-licences and supermarkets—nor as available. Although approaches to increase price and reduce availability smack of the “nanny state,” it is simplistic to dismiss alcohol dependence and physical damage as lifestyle diseases, somehow down to the individual’s free choice and nothing to do with the state. Cheap drink is available and heavily promoted. Alcohol is our favourite drug, and it is distressing to see young women pressured into misusing it.
Competing interests: IG is chairman of the UK Alcohol Health Alliance.
Provenance and peer review: Commissioned; not externally reviewed.