Evidence for a closing gender gap in alcohol use, abuse, and dependence in the United States population

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Abstract

Background

Descriptively, male–female differences in alcohol consumption and alcohol use disorders appear to have decreased in birth cohorts reaching adulthood since the 1970s compared to earlier birth cohorts. However, such birth cohort effects on gender differences have never been statistically tested in nationally representative data. The aim of this study was to test the hypothesis that gender differences in alcohol consumption, abuse, and dependence are decreasing over time.

Methods

Face-to-face survey conducted in the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions among those aged <90 (N = 42,693). Birth cohort was divided into four categories: 1913–1932, 1933–1949, 1950–1967, 1968–1984. Outcomes included lifetime largest drinks, frequent binge drinking, DSM-IV defined alcohol abuse, and alcohol dependence, measured with the Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS-IV).

Findings

Birth cohort and gender interacted significantly in predicting lifetime largest drinks (F = 27.6, [d.f. = 3], p < 0.0001), frequent binge drinking (F = 40.0, [d.f. = 3], p < 0.0001), alcohol abuse (F = 62.0, [d.f. = 3], p < 0.0001) and alcohol dependence (F = 15.3, [d.f. = 3], p < 0.0001). Cohort-specific ORs indicated monotonic decreases in the gender ratio in more recent birth cohorts for all outcomes.

Conclusion

These results suggest that gender differences in the prevalence of all four outcomes are decreasing in younger age cohorts. While these changes are consistent with a cohort effect, the possibility of age and period effects cannot be ruled out but suggest important avenues for more specific hypothesis testing. Further, women in younger cohorts may be in need of new targeted prevention and intervention efforts.

Introduction

Men have been consistently shown to drink more alcohol and have a higher likelihood of alcohol use disorders than women in the United States (Grant, 1997, Helzer and Pryzbeck, 1988, Warner et al., 1995) and internationally (Wilsnack et al., 2000). In the U.S., “traditional” gender roles have changed since the baby boom birth cohort reached adulthood in the 1970s. Since then, the proportion of women working outside the home has increased, while the proportion of women having children has decreased (Thronton and Freedman, 1983, Echols, 1989, Rosen, 2000). Consistent with these changes in “traditional” behaviors, differences in gender-based drinking norms have diminished since the 1970s (Greenfield and Room, 1997). Diminished gender differences in the prevalence of alcohol use disorders as a function of birth cohort would be consistent with these other large social changes, but such information is lacking. A more comprehensive understanding of the relationship of birth cohort to alcohol disorders has important implications for our knowledge of etiology of these prevalent and often disabling disorders (Hasin et al., 2007). Evidence that gender differences in alcohol consumption and alcohol use disorders have changed across successive U.S. birth cohorts would indicate the need to investigate how such gender differences in alcohol use disorders occurred within larger population-level gender role shifts. Moreover, the identification of secular trends in alcohol-related outcomes has important implications for researchers investigating risk factors at other levels of organization. For instance, the magnitude of association between a genetic risk factor and alcohol dependence could vary across populations as a function of the trends in alcohol disorder prevalence across time.

To understand birth cohort effects on gender differences in the likelihood of alcohol use disorders, overall birth cohort shifts in prevalence must be understood. U.S. per capita alcohol consumption began an upward trend at the repeal of Prohibition in 1933 that peaked in the early 1980s (Lakins et al., 2005). While National Alcohol Survey data indicate that cohort effects may vary by beverage type (Kerr et al., 2004), most large-scale cross-sectional studies have indicated an increase in the prevalence of alcohol use and alcohol use disorders by birth cohort. The National Household Surveys on Drug Abuse indicated a cohort effect for any alcohol use, with individuals born in cohorts after 1950 particularly more likely to use alcohol than those born previously (Johnson and Gerstein, 1998). The National Longitudinal Alcohol Epidemiologic Survey (NLAES) and the National Comorbidity Study (NCS) both suggest that birth cohorts after World War II evidence heightened risk for alcohol use (Grant, 1997) and lifetime alcohol disorders (Anthony et al., 1994, Warner et al., 1995, Grant, 1996, Grant, 1997) compared with earlier birth cohorts. Although cross-sectional studies cannot empirically establish the existence of a cohort effect as opposed to a period (factors impacting risk among all members of a population at a given point in time) or age effect (factors impacting risk at specific ages), these shifts in the prevalence of alcohol disorders in the population are consistent with a cohort effect because respondents within birth cohorts are similar to each other with respect to alcohol consumption and alcohol use disorders across the lifecourse, as opposed to all cohorts being similar at a single point in time (a period effect) or all individuals across birth cohorts having the same risk at a given age (age effect).

While studies of adolescent alcohol use have consistently shown a convergence in rates of alcohol use initiation in younger birth cohorts (Engs and Hanson, 1990, Johnson and Gerstein, 1998, Johnston et al., 2004, Johnston et al., 2005, Schulenberg et al., 2001), studies of adults are less consistent. In The Netherlands, convergence was suggested by linear increases in average weekly alcohol consumption during a time when consumption among men decreased (Saelan et al., 1992, Neve et al., 1993), although this effect was not seen for weekly heavy (≥6 drinks) drinking (Neve et al., 1996). Converging rates of mean weekly drinking due mainly to increases among women by cohort were found in a survey in Finland, but not in Germany, Switzerland, or the Netherlands (Bloomfield et al., 2001). In New Zealand, gender differences in alcohol consumption decreased from 1995 to 2000, due mainly to increases among women in typical quantity/frequency (e.g., consuming more than 20 l of alcohol per annum and drinking enough to feel drunk once per week (McPherson et al., 2004)). In surveys of U.S. women from 1981 to 2001, complete abstention and heavy episodic drinking (≥6 drinks/day) both decreased over time (Wilsnack et al., 2006), but these surveys did not include males, so direct gender comparisons could not be made. These studies of alcohol consumption differed widely in their measures and study design, and thus their lack of consensus on gender differences in alcohol consumption is difficult to interpret.

In contrast to the literature on alcohol consumption, studies of DSM-IV alcohol use disorders have been more consistent, although most evidence comes from family genetic studies, which are not representative samples. Among relatives of 300 Caucasian alcohol dependent individuals (Reich et al., 1988), secular trends in the consumption of alcohol contributed to an increased prevalence of alcohol dependence over time, and sex differences in alcohol consumption and problem alcohol behaviors decreased. In a Midwestern Caucasian twin study, individuals born after 1951 were at higher risk for DSM-IV alcohol dependence than those born earlier, a risk that was more pronounced for women (Holdcraft and Iacono, 2002). The Collaborative Study on the Genetics of Alcoholism (COGA) noted a decrease in the gender gap in the prevalence of DSM-IV defined alcohol dependence among those born in younger cohorts compared to earlier-born cohorts, but did not directly test for the presence of effect modification (Rice et al., 2003). These studies were all limited in terms of generalizeability. In contrast, the NLAES, a 1991–1992 U.S. national survey of over 42,000 adults, provided a substantial advantage in terms of sample size and representativeness. Descriptively, male and female prevalences by birth cohort suggested that gender differences in alcohol use disorders had decreased in younger cohorts (Grant, 1997). However, this apparent difference was never directly tested. These studies suggest birth cohort effects on the gender ratio in the prevalence of DSM-IV alcohol use disorders, and point to the need for direct testing in a recent, large, representative sample.

In sum, there is evidence to suggest that non-parallel male and female trends in recent birth cohorts have decreased the gender gap in alcohol consumption. However, the existence of such a phenomenon has never been directly tested in a representative sample. Accordingly, the present study uses such a sample, the U.S. National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), to investigate whether there is evidence consistent with a birth cohort effect on gender differences in the prevalence of DSM-IV alcohol abuse and dependence. We also examined such effects for drinking and frequent binge drinking to determine if the effects were consistent across different alcohol indicators, and to provide links to earlier studies. The NESARC sample is uniquely situated to address these questions. The sample size is large enough to detect interaction effects, the state-of-the-art diagnostic instrument provides reliable, valid and complete diagnostic information on both alcohol dependence and abuse, and the sample includes individuals born more recently than previous large-scale studies.

Section snippets

Sample

This sample consists of participants in the 2001–2002 the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative United States survey of 43,093 civilian non-institutionalized participants aged 18 and older, sampled cross-sectionally and interviewed in person. Details of the sampling frame are described elsewhere (Grant et al., 2003, Grant et al., 2004). The National Institute on Alcohol Abuse and Alcoholism (NIAAA) sponsored the study and

Mean largest drinks

Table 1 indicates the mean lifetime largest number of drinks consumed by birth cohort and gender. In the total sample, men consumed 6.94 mean drinks (inter-quartile range 2–10) compared to 2.98 mean drinks (inter-quartile range 0–4) for women. This represented a 2.33:1 male/female ratio. When dividing by cohort, there are increases in mean drinks consumed with each successively younger cohort in both men and women. Additionally, there is a slight reduction in the male/female ratio. In Cohort 1,

Discussion

We examined overall rates and gender differences in alcohol consumption, binge drinking, alcohol abuse and dependence by birth cohort in the U.S. general population, and conducted statistical tests of whether birth cohort modified the magnitude of gender differences in the lifetime prevalence of these four important alcohol variables. The results showed substantial, monotonic decreases in gender differences between the oldest and youngest cohorts for all alcohol variables, confirmed by the

Conflict of interest

None.

Acknowledgement

We thank Valerie Richmond M.A. for manuscript preparation and editorial assistance.

Role of funding source: This research was supported in part by grants from the National Institute on Alcoholism and Alcohol Abuse (K05 AA014223, Hasin) and the National Institute on Drug Abuse (RO1 DA018652, Hasin); the Intramural Program of the National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism; and support from New York State Psychiatric Institute. No funding source had any

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