One mojito, two mojitos, three mojitos ... FLOOR! The message in a popular birthday card shows how ubiquitous alcohol is in our society. It's linked to our notions of celebration, sophistication and well-being. It's how we relax, reward, escape - exhale.
Know your wines? You're affluent. Know your vodkas? You're hip. Know your coolers, your shots? You're young and female.
Alcohol abuse is rising in much of the developed world - and in many countries, female drinkers are driving that growth. This is global: the richer the country, the fewer abstainers and the smaller the gap between male and female consumption. The new reality: binge drinking is increasing among young adults - and women are largely responsible for this trend. What has not been fully documented, understood or explored is that while women have gained equality in so many arenas, we have also begun to close the gender gap when it comes to alcohol abuse.
The alcohol industry, well aware of women's buying power, is now battling for our downtime - and our brand loyalty.
When it comes to alcohol, we live in a culture of denial. With alcoholics representing 2-7 per cent of the population, depending on the country, it's the widespread normalisation of heavier consumption that translates to serious trouble. In the Western world, most of us drink. And the top 20 per cent of the heaviest drinkers consume roughly three-quarters of the alcohol sold. Episodic binge drinking by a large population of non-dependent drinkers has a huge impact on society. This group is well represented in the numbers missing work, getting injured or being hospitalised. When compared to those who drink moderately, risky drinkers are more than 12 times as likely to report significant harms, ranging from violence to car crashes.
Most of us understand the major role that chronic alcohol abuse plays in family disruption, violence and injury. Death? When compared to illicit drugs, there are many more deaths due to alcohol. Women most likely to binge drink are those between the ages of 18 and 34 - in others words, those in prime child-bearing years.
Binge drinking not only increases the risk of unintended pregnancies: if pregnant women binge, their babies are at risk of sudden infant death syndrome and fetal alcohol spectrum disorders. Binge drinking increases the risk of breast cancer, heart disease and sexually transmitted diseases, among others.
Sitting in her office, her 2-year-old son's face beaming by her computer, Katherine Keyes, now an assistant professor at Columbia University, gets specific: "Those born between 1978 and 1983 are the weekend warriors, drinking to black out.
"In that age group, there is a reduction in male drinking, and a sharp increase for women."
Meanwhile, women who are in their 40s and 50s have a very high risk in terms of heavy drinking and weekly drinking.
"We're not saying, 'Put down the sherry and go back to the kitchen'," says Keyes. "But when we see these steep increases, you wonder if we are going to see a larger burden of disease for women."
In many countries, the answer is yes. Take Britain, for instance, the Lindsay Lohan of the international set. Most important, Keyes' study points to the critical role of societal elements in creating a drinking culture. "Traditionally, individual biological factors have been the major focus when it comes to understanding alcohol risk," says Keyes. "However, this ignores the impact of policy and environment."
The environment is challenging: witness the rise in alcohol marketing, the feminisation of the drinking culture. Women need a break. They feel they deserve a break. And if drinking is about escape, it is also about entitlement and empowerment.
Says Keyes: "Those in high-status occupations, working in male-dominated environments, have an increased risk of alcohol use disorders."
In fact, the one protective factor for women is what Keyes calls low-status occupations. "As gender role traditionality decreased, the gender gap in substance abuse decreased as well. And the trajectory for female alcohol abuse now outpaces that of men."
In fact, women with a university degree are almost twice as likely to drink daily as those without. Says Katherine Brown, director of policy at Britain's Institute of Alcohol Studies: "Young professional women drink a lot more than women in manual and routine jobs. Is it marketing, keeping up with the machismo, children?"
Brown believes the "alcohol-soaked environment" of university sets the stage for working life. "Now, it's the 'done' thing for a city woman to come home after a stressful day and open a bottle of wine. Nobody questions it."
Walk into most social gatherings and the first thing you're asked is "Red or white?" We live in a culture where knowing your wines is a mark of sophistication. And thanks to media reports we have happily absorbed the news that drinking has health benefits. For many, red wine ranks up there with vitamin D, omega-3s, and dark chocolate. If one glass is good for you, a double dose can't do much harm, can it? Actually, a double dose has its drawbacks.
Which raises a simple question: why are we aware of the dangers related to trans fats and tanning beds, and blissfully unaware of the more serious side effects associated with our favorite drug? It's a head-scratcher, to say the least.
Last year, a study in the respected journal Addiction challenged the broadly accepted assumption that a daily glass of red wine offers protection against heart disease.
Says Jurgen Rehm, director of social and epidemiological research at Toronto's Centre for Addiction and Mental Health and coauthor of the paper: "While a cardio-protective association between alcohol use and ischemic heart disease exists, it cannot be assumed for all drinkers, even at low levels of average intake. And, the protective association varies by gender - with higher risk for morbidity and mortality in women."
Alcohol is a carcinogen, and the risks of drinking far outweigh the protective factors. For some time there has been a clear causal link between alcohol and a wide variety of cancers, including two of the most frequently diagnosed: breast and colorectal. Rehm asks a simple question: "What would the breast cancer rate be without alcohol?"
Not only are young women experimenting with the strongest beverage, shots, but they're more vulnerable because of the way alcohol metabolises in female bodies. "If you're female and you're drinking spirits, and the guy's drinking beer, you're at a complete disadvantage," says David Jernigan, director of the centre on Alcohol Marketing and Youth.
"He's drinking a weaker beverage, he's metabolising it more efficiently, and you're trying to keep up. And you've got Carrie Bradshaw saying that this is the image of the powerful woman - a woman with a cocktail in her hand virtually every moment that you see her, except when she's trying on shoes!"
Can we really blame Carrie Bradshaw for the martini-shots-vodka culture?
"Let's put it this way," says Jernigan. "We cannot discount Carrie Bradshaw. But if Carrie Bradshaw hadn't been accompanied by a push by the spirits industry, she would have been a pebble in the pond. As it was, she was a boulder."
There are many consequences to drinking young, not the least of which is vulnerability to sexual assault.
Says Jernigan: "If you drink before age 15, you're four times more likely to become alcohol dependent than those who waited until they were 21; seven times more likely to be in a motor vehicle crash after drinking; eight times more likely to experience physical violence after drinking; 11 times more likely to experience other injuries like drownings and falls. The bottom line? There's a strong public health interest in delaying the onset of drinking."
Richard Grucza is a renowned alcohol epidemiologist at the Washington University School of Medicine in St Louis, Missouri. "Kids who start early are just different," he says. "Drinking early is a very strong risk factor for alcoholism. Hundreds of studies show this. In fact, there is a 25 per cent increase in risk for alcohol dependence in those who drink at an early age."
Some parents believe that allowing their sons and daughters to drink at the dinner table will innoculate them against future risky drinking. In fact, a quarter of mothers in a recent American study believed that allowing their third-grader children an alcoholic beverage would discourage them from wanting to drink as teenagers: the taste would put them off. The more educated the mother, the more likely she will be what is known as "pro-sipping".
Others cite the Mediterranean model of allowing young people a taste as a way of modelling moderation.
This, according to one Italian mother, is pure folly. "Young teenagers do not drink with their families at the table the way we did when we were growing up," says Tiziana Codenotti of Padua. "They drink premixed lemonade and alcohol, and on Friday night they binge. A big group will head to the square and no one knows how to deal with it."
In other words, parental influence is important, but so too are peers. Italian youth are drinking the same way as American youth and Australian youth. All are influenced by the surround-sound marketing environment of Facebook, YouTube and TV.
Andrew Galloway, a prominent Toronto interventionist, says younger girls often drink for different reasons than boys.
"Guys drink for the buzz and to be social. Girls drink because of lack of self-esteem, to cope, to feel a part of - and because of peer pressure."
Ten-year-olds don't just voluntarily decide to use alcohol, says Elizabeth Saewyc, a lead researcher in a Canadian study exploring early use among adolescents. Several key factors help tip the scales as to whether a person will drink at an early age.
Number one: a history of sexual or physical abuse, or trauma. "If this is your history," says Saewyc, "you are far more likely to start at 12 or younger. If we could eliminate all violence - bullying, sexual and physical abuse, sexual harassment - we could prevent 66 per cent of binge drinking in 12-to-18-year-olds."
Other key factors related to early drinking: a mental health condition or a chronic physical issue, poverty, identifying as gay, lesbian, or bisexual. "They are more likely to be targets of violence," says Saewyc, "and more likely to have problems drinking."
Another factor is a family history of attempting suicide. Females who start drinking at a younger age are more likely to report experiencing extreme despair, purging after eating, having suicidal thoughts, and having attempted suicide.
Drinking to escape
"For the first time, I find myself drinking much more than I had expected.
Those evenings surprise me. I realise that I am drinking to escape. I find myself slurring when I intend to be witty. This is not working. In fact, very little is working. My husband has asked for a separation; we have a beautiful 2-year-old, a century-old home with a view of the water, great jobs.
My husband Will and I decided to give it another try, but each day is difficult. I know our marriage is on trial and my future is at stake.
My husband brings me white wine spritzers, a peace offering. At first I say no: too risky. But, gradually, I say yes. We begin to see a new marriage counsellor, and I see her separately for depression. Will I take antidepressants, she asks? No, I say. I'll tough it out. My mother's experience with Valium haunts me.
Winter of 1990: my marriage ends. Our son Nicholas is only 5. I am determined to keep my little family together. On Sunday nights, Will comes for dinner. Each evening, after we put Nicholas to bed, we find ourselves having several glasses of wine, discussing how this will unfold.
A ticking champagne bomb
"I remember an awkward moment on my first sober birthday. Arriving at my favourite restaurant with my handsome 23-year-old son, I met with a difficult situation.
The owner, who knew me all too well, delivered stems of champagne as we sat down, a red raspberry floating in each glass. I was only four months out of rehab.
Both Nicholas and I froze.
"Get him to take them away," whispered my son.
"Let's just give it a minute," I whispered back, reluctant to cause a scene. With that, my son stood up and exited the restaurant.
It took 20 awkward minutes and a few tears before the evening resumed.
There's a beautiful photo of us at our table that night, one I still can't look at without wincing.
Cold comfort for alpha women
Is alcohol the modern woman's steroid, enabling her to do the heavy lifting needed in a complex, demanding world?
For many women, the answer is yes. Racing in from a long day at the office, an evening of cooking and homework ahead, the first instinct is to pop a cork, soothing the transition from day to night with a glass of white or red.
For years this was my habit, and it seemed harmless. My house wine was Santa Margherita, a pale straw-blonde Pinot Grigio. There was always a bottle in my fridge, and I'd often pour a second glass before dinner, with seeming impunity.
With two parents who had their own serious troubles with alcohol, alarm bells should have been ringing. But truth was, I got a lot done when I was drinking.
In my alpha-dog years - when I was holding down a senior job at a magazine, raising an artistic, athletic young man - life was more than full. Alcohol smoothed the switch from one role to the other. I could juggle a lot. Until, of course, I couldn't. That's the thing about a drinking problem: it's progressive.
But for a long time, alcohol can step in as an able partner - before you want to boot it out.
Win a drink
We are giving away 10 copies of Drink, the intimate relationship between women and alcohol by Ann Dowsett Johnston (HarperCollins New Zealand, RRP $39.99).
To enter, visit www.winwithheraldonsunday.co.nz and enter the keyword DRINK along with your details. Entries close on Wednesday at midnight.