The Healthcare Professional's

Core Resource on Alcohol

Knowledge. Impacts. Strategies.

National Institute on Alcohol Abuse and Alcoholism (NIAAA)

Risk Factors: Varied Vulnerability to Alcohol-Related Harm

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    Takeaways

    • Knowing which patient groups are at greater risk for alcohol-related harm can reinforce your efforts to conduct careful screening, assessment, advising, and referral.
    • Risks for alcohol-related harm vary by a wide range of factors, including your patient’s age, gender, sexual minority status, genes, mental health, and exposure to trauma or other stressors.
    • While being cognizant of varied vulnerabilities, it’s best to adopt a “we screen everyone” approach. See the Core articles on screening and practice change.

    A common but misguided stereotype of a person with alcohol-related problems is of someone who is “down and out.” People across all walks of life, however, are vulnerable to developing problematic drinking patterns and alcohol-related harms such as injuries, medical complications, social or interpersonal troubles, and alcohol use disorder (AUD) (see Core article on AUD).

    Here, we briefly describe the variety of alcohol-related risks faced by different patient groups, which we hope will help you spot red flags early and respond accordingly. Nevertheless, alcohol-related harm can happen to anyone, so it is best to adopt a “we ask everyone” approach, which normalizes alcohol screening and may help reduce patient perceptions of being singled out for attention to their drinking. (See Core articles on screening and practice change.)

    A note on drinking level terms in this Core article: Binge drinking brings a person’s blood alcohol concentration to 0.08 percent or more, which typically happens if a woman has 4 or more drinks, or a man has 5 or more drinks, within about 2 hours. Heavy drinking includes binge drinking and has been defined for women as 4 or more drinks on any day or 8 or more per week, and for men as 5 or more drinks on any day or 15 or more per week.

    What are the risks in different age groups?

    Adolescents: Brain development disruptions, future AUD, and more. Underage drinking remains common. According to a 2022 national survey, about 7% of youths aged 12-17 drank alcohol in the past month, and about half of them, or 3.2% total, had a binge drinking episode in the past month.1,2 Drinking alcohol poses considerable risks to adolescents and should not be considered a normal, expected part of teenage life. During adolescence, heavy drinking can disrupt critical brain development patterns by accelerating the volume decline in frontal cortical gray matter that typically occurs in early adolescence,3,4 and by slowing the volume increase in white matter that typically occurs in late adolescence.5 Heavy drinking in adolescence also predicts future AUD, with the earlier the onset of drinking, the greater the AUD risk.6,7

    Moreover, heavy or binge drinking during adolescence is associated with other risky behaviors, including tobacco and drug use, unprotected sex, poor school performance, conduct problems, impaired driving, and suicide.8 Heavy drinking may also be a clue to the presence of depression or anxiety in both adolescents and adults (see below and Core article on mental health issues). Given rising rates of depression and suicidal ideation among adolescents,9 screening adolescents for both alcohol use and mood disorders has become increasingly important.

    Young adults: At greatest risk for AUD. The age range of 18 to the late 20s is the period of emerging or young adulthood. Brain development is still occurring, adult identities are forming, and transitions such as starting college present increased alcohol-related risk and opportunities for intervention. By young adulthood, drinking alcohol is far more prevalent than during adolescence, including among those under age 21 for whom drinking is illegal.

    According to a 2022 national survey, about 50% of young adults aged 18-25 drank alcohol in the past month and of them, about 60% also had a binge drinking episode in the past month.1 Perhaps surprisingly, the survey found higher rates of past-year AUD among young adults compared to other age groups, affecting approximately 1 in 6 of those aged 18-25.10 A previous national survey also found that young adults aged 18-29 had by far the highest prevalence of past-year AUD.11 In addition, the prevalence of heavy drinking is higher among college students than among same-age peers, perhaps because college students may have more opportunities for high-volume drinking and may delay assuming roles of adult responsibility.12 Young adult males in general are more likely to drink heavily than their female peers, but this gender gap has been narrowing since the 1990s13 (see risks by gender, below).

    Late 20s to mid-life adults: “Maturing out” vs. persistent heavy drinking. Many people who drank heavily in their young adult years reduce their drinking substantially over time, a phenomenon known as “maturing out” of heavy drinking.14,15 Maturing out of heavy drinking is often attributed to transitions to adult roles such as marriage, parenthood, and full-time employment that are incompatible with persistent heavy drinking. In contrast, some individuals who drink heavily as young adults persist in this pattern into middle age. Others first develop alcohol problems in middle age. In either case, studies have found that people with AUD commonly seek treatment in their mid-30s to early 50s.16–19

    Older adults: Increased risk of harms. Heavy drinking and AUD are least common among adults aged 65 and older compared to other age groups,11 but rates have been increasing.20,21 A 2022 analysis of national survey data showed that an estimated 1 in 10 adults in this age group had 5 or more drinks (men) or 4 or more drinks (women) on at least one occasion in the past month,22 and an estimated 1 in 25 had AUD in the past year.23 Age-related changes in how the body processes alcohol present added problems since a given dose of alcohol may lead to greater intoxicating effects in older adults compared to younger adults.24–26 The increased sensitivity to alcohol in older adults raises their risk for many health problems, including injuries (commonly from falls), memory problems, liver disease, sleep problems, and overall mortality.27 Moreover, drinking alcohol at any level poses increased risks for older adults because they are more likely than younger people to take medications, many of which have the potential to interact negatively with alcohol.28 (See Core article on medication interactions.)

    What are the risks by gender?

    Narrowing gender gap in consumption. Historically, men have had higher rates of alcohol consumption, alcohol-related consequences, and AUD than women.11,13 A 2019 critical review of national studies conducted since 2008 concluded that this gender gap in heavy drinking and alcohol problems has noticeably narrowed, though trends in alcohol use vary by age group.13 For example, among adolescents and young adults, rates of alcohol consumption, binge drinking, and various alcohol-related harms have declined in both males and females, but more so for males.13 In middle and older adulthood, alcohol consumption, binge drinking, and alcohol-related harms are increasing, but at a faster rate for women than men.13

    Heightened harms in women. Women tend to suffer a variety of harms at lower levels of alcohol exposure than men. For instance, women with AUD perform more poorly than men with AUD on a variety of cognitive tasks, even with fewer years of AUD.29 Women are at greater risk than men for alcohol-related health problems, including liver inflammation, cardiovascular diseases, and certain cancers.30–32 A single serving of alcohol per day is associated with a 10% increase in the risk of breast cancer for women.33 Over the past few decades, rates of alcohol-related emergency department visits, hospitalizations, and deaths from alcohol associated liver disease and other alcohol-related causes have all increased, but at a faster rate for women than men.34–36 And women (as well as men) who drink heavily are at increased risk of being the victim of secondhand harms, such as physical aggression, by others who have been drinking.37

    Increased prevalence of AUD in women of sexual minority status. Among those with sexual minority status such as being gay or lesbian, different drinking patterns and rates of AUD emerge for men and women. Numerous studies have found that the likelihood of heavy drinking or AUD is substantially greater among women who are sexual minorities (based on sexual identity, behavior, or attraction) than among heterosexual women.38–40 However, in contrast, the likelihood of heavy drinking or AUD among gay men is similar to that in heterosexual men.38–40 Note: these studies specifically report on people of sexual minority status, but not gender minority status, such as transgender people. More quality studies are needed on alcohol risks among gender minorities.41

    What are the risks of prenatal alcohol exposure?

    Alcohol can have harmful effects throughout gestation, with heavy drinking thought to be particularly damaging.42,43 Prenatal alcohol exposure can cause lifelong physical, behavioral, and cognitive impairments collectively known as fetal alcohol spectrum disorders (FASD). In a 2018 study of more than 13,000 first-grade children in the U.S., researchers estimated that between 1% and 5% of the children they assessed had FASD.42

    Because no level of alcohol consumption has been found to be safe during pregnancy, obstetric and pediatric guidelines advise abstinence through pregnancy.44–46 About 1 in 9 pregnant women drink, predominantly in the first trimester, and almost half of them report drinking heavily.47,48 Alcohol exposure during the first trimester appears to be particularly detrimental, but even low levels of alcohol exposure throughout pregnancy are associated with morphological, cognitive, and motor deficits.43,49,50 For more information on FASD, see the Core article on medical complications. For guidance for healthcare professionals on FASD prevention, diagnosis, and care, see the resources below.  

    What is the risk from genetic vulnerability to AUD?

    Between 50% and 60% of the vulnerability to AUD is inherited51,52 and likely due to variants in many genes, each of small effect size. Different genes confer risk by affecting various biological processes and mental states and traits, including, for example, physiological responses to alcohol and stress, alcohol metabolism, addiction-related neurobiology, and behavioral tendencies such as impulsivity.52 As a few examples:

    • Inherited responses to alcohol. Individuals who can “hold their liquor” may have an inherited low level of response to alcohol (that is, an innate alcohol tolerance) that puts them at increased risk for heavy drinking and AUD.53–56 Your patients may be unaware that being able to “drink people under the table” isn’t protective from alcohol problems, but instead is a reason for caution. In addition, people who experience stimulating rather than sedating effects from alcohol are more likely to drink heavily and develop AUD.57–59
    • Inherited alcohol metabolism. An estimated 36% of people of East Asian descent (Chinese, Japanese, and Korean heritage) carry variations in genes that influence the form of liver enzymes responsible for ethanol metabolism (see the Core basics article).60–62 These variants can cause a buildup of acetaldehyde, which leads to facial flushing, nausea, and tachycardia when alcohol is consumed.62 Although this response may limit drinking, in individuals who do drink, these variants carry an increased risk for esophageal cancer, even among people who are lighter drinkers.62–64 In addition to those of East Asian descent, people of other races and ethnicities can carry variations in these genes.65
    • Inherited vulnerability to different elements of addiction. A 2017 review of genetic studies of AUD summarized numerous additional genetic loci associated with AUD or related traits,51 including, for example, genes related to addiction-related neurotransmitter systems (see Core article on neuroscience).These genetic studies offer promise in achieving a better understanding of the biological mechanisms leading to the development of AUD.

    How does stress put people at risk for AUD?

    A complex interplay of genetic and environmental factors influences both drinking patterns and AUD risk. Among the environmental risk factors for AUD, external stress is one of the most potent.66 Your patients who experienced trauma, particularly in childhood, or an accumulation of significant stressors throughout life, may be prone to heavy drinking patterns and increased AUD risk.66,67 A person’s stress response is influenced by the type of stressor and its intensity, timing, and duration, as well as by the person’s genetic makeup and drinking history. For more information on the complex links between alcohol, stress, and AUD, see NIAAA’s journal issue on stress and alcohol.

    How do mental health conditions affect the risk for AUD (and vice versa)?

    The interplay of genetic and environmental factors can also prompt the development of mental health conditions such as anxiety and depression that raise the risk of developing AUD.16,52,68 At the same time, AUD can cause or worsen anxiety, depression, or other mental health issues. Thus, co-occurrence of AUD and other mental health conditions is common (see Core article on mental health issues). For example:

    • Among those being treated for anxiety disorders, the prevalence of AUD is in the range of 20% to 40%.69,70
    • Among those who have had a major depressive disorder in their lifetime, up to 40% also have had AUD.69
    • Among those with AUD:
      • about 15-30% overall have co-occurring post-traumatic stress disorder, with increased rates of 50-60% among military personnel and veterans.71
      • about 40% of men and almost 50% women have had another substance use disorder in their lifetime.69
      • estimates of the prevalence of sleep disorders range from 36% to 91%.72

    A neuroscience framework for individual differences in risk for AUD

    An assessment framework called the Addictions Neuroclinical Assessment (ANA) has been developed that takes a precision medicine approach by integrating neuroscience, neuroimaging, and clinical data to identify domains of dysfunction that may be relevant to a person’s vulnerability to addiction, to treatment, and to recovery. In the ANA framework, there are three functional domains relevant to addiction (incentive salience, negative emotionality, and executive function), which align with the three stages of the addiction cycle model described in the Core article on neuroscience.73 In a 2019 ANA analysis of individuals who drank heavily, those with AUD reported more executive function deficits, incentive salience, and negative affect, compared with those without AUD.74 Psychiatric disorders associated with deficits in executive function (such as attention-deficit/hyperactivity disorder) or with heightened negative affect (such as depression or anxiety) may increase risk for developing AUD and complicate treatment and prognosis. For more on comorbid psychiatric disorders, see the Core article on mental health issues.

    In closing, risks for alcohol-related harm are influenced by a wide range of factors, and alcohol-related harm can happen to anyone. Thus, it’s best to adopt a “we screen everyone” approach. See the Core articles on screening and practice change for tips to support you and your practice.

    Resources

    Fetal Alcohol Spectrum Disorders

    More resources for a variety of healthcare professionals can be found in the Additional Links for Patient Care.

    References

    1. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. 2022 National Survey on Drug Use and Health: Table 2.27B – Alcohol Use in Past Month: Among People Aged 12 or Older; by Age Group and Demographic Characteristics, Percentages, 2021 and 2022. Accessed January 3, 2024. https://www.samhsa.gov/data/report/2022-nsduh-detailed-tables
    2. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. 2022 National Survey on Drug Use and Health: Table 2.28B – Binge Alcohol Use in Past Month: Among People Aged 12 or Older; by Age Group and Demographic Characteristics, Percentages, 2021 and 2022. Accessed January 3, 2024. https://www.samhsa.gov/data/report/2022-nsduh-detailed-tables
    3. Crews FT, Robinson DL, Chandler LJ, et al. Mechanisms of Persistent Neurobiological Changes Following Adolescent Alcohol Exposure: NADIA Consortium Findings. Alcohol Clin Exp Res. 2019;43(9):1806-1822. doi:10.1111/acer.14154
    4. Ruan H, Zhou Y, Luo Q, et al. Adolescent binge drinking disrupts normal trajectories of brain functional organization and personality maturation. NeuroImage Clin. 2019;22:101804. doi:10.1016/j.nicl.2019.101804
    5. Pfefferbaum A, Desmond JE, Galloway C, Menon V, Glover GH, Sullivan EV. Reorganization of Frontal Systems Used by Alcoholics for Spatial Working Memory: An fMRI Study. NeuroImage. 2001;14(1):7-20. doi:10.1006/nimg.2001.0785
    6. Hingson RW, Heeren T, Winter MR. Age at drinking onset and alcohol dependence: age at onset, duration, and severity. Arch Pediatr Adolesc Med. 2006;160(7):739-746. doi:10.1001/archpedi.160.7.739
    7. Hingson R, Heeren T, Zakocs R, Winter M, Wechsler H. Age of first intoxication, heavy drinking, driving after drinking and risk of unintentional injury among U.S. college students. J Stud Alcohol. 2003;64(1):23-31. doi:10.15288/jsa.2003.64.23
    8. Windle M. Drinking Over the Lifespan: Focus on Early Adolescents and Youth. Alcohol Res Curr Rev. 2016;38(1):95-101.
    9. Twenge JM, Cooper AB, Joiner TE, Duffy ME, Binau SG. Age, period, and cohort trends in mood disorder indicators and suicide-related outcomes in a nationally representative dataset, 2005-2017. J Abnorm Psychol. 2019;128(3):185-199. doi:10.1037/abn0000410
    10. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. 2022 National Survey on Drug Use and Health: Table 5.9B – Alcohol Use Disorder in Past Year: Among People Aged 12 or Older; by Age Group and Demographic Characteristics, Percentages, 2021 and 2022. Accessed January 3, 2024. https://www.samhsa.gov/data/report/2022-nsduh-detailed-tables
    11. Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 Alcohol Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry. 2015;72(8):757-766. doi:10.1001/jamapsychiatry.2015.0584
    12. Merrill JE, Carey KB. Drinking Over the Lifespan: Focus on College Ages. Alcohol Res Curr Rev. 2016;38(1):103-114.
    13. Keyes KM, Jager J, Mal-Sarkar T, Patrick ME, Rutherford C, Hasin D. Is There a Recent Epidemic of Women’s Drinking? A Critical Review of National Studies. Alcohol Clin Exp Res. 2019;43(7):1344-1359. doi:10.1111/acer.14082
    14. Windle M. Sex differences in substance use from adolescence to young adulthood: Tests of increases in emergent adulthood and maturing out in later young adulthood. Drug Alcohol Depend. 2020;207:107813. doi:10.1016/j.drugalcdep.2019.107813
    15. Lee MR, Sher KJ. “Maturing Out” of Binge and Problem Drinking. Alcohol Res Curr Rev. 2018;39(1):31-42.
    16. Cohen E, Feinn R, Arias A, Kranzler HR. Alcohol treatment utilization: findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Drug Alcohol Depend. 2007;86(2-3):214-221. doi:10.1016/j.drugalcdep.2006.06.008
    17. Kelly JF, Humphreys K, Ferri M. Alcoholics Anonymous and other 12‐step programs for alcohol use disorder. Cochrane Database Syst Rev. 2020;2020(3). doi:10.1002/14651858.CD012880.pub2
    18. Rohn MCH, Lee MR, Kleuter SB, Schwandt ML, Falk DE, Leggio L. Differences Between Treatment-Seeking and Nontreatment-Seeking Alcohol-Dependent Research Participants: An Exploratory Analysis. Alcohol Clin Exp Res. 2017;41(2):414-420. doi:10.1111/acer.13304
    19. Haass‐Koffler CL, Piacentino D, Li X, et al. Differences in sociodemographic and alcohol‐related clinical characteristics between treatment seekers and nontreatment seekers and their role in predicting outcomes in the COMBINE study for alcohol use disorder. Alcohol Clin Exp Res. 2020;44(10):2097-2108. doi:10.1111/acer.14428
    20. Han BH, Moore AA, Sherman S, Keyes KM, Palamar JJ. Demographic trends of binge alcohol use and alcohol use disorders among older adults in the United States, 2005–2014. Drug Alcohol Depend. 2017;170:198-207. doi:10.1016/j.drugalcdep.2016.11.003
    21. Han BH, Moore AA, Ferris R, Palamar JJ. Binge Drinking Among Older Adults in the United States, 2015 to 2017. J Am Geriatr Soc. 2019;67(10):2139-2144. doi:10.1111/jgs.16071
    22. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. 2022 National Survey on Drug Use and Health: Table 2.9B – Alcohol, Binge Alcohol, and Heavy Alcohol Use in Past Month: Among People Aged 12 or Older; by Detailed Age Category, Percentages, 2021 and 2022. Accessed January 3, 2024. https://www.samhsa.gov/data/report/2022-nsduh-detailed-tables
    23. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. 2022 National Survey on Drug Use and Health: Table 5.3B – Drug Use Disorder, Alcohol Use Disorder, and Substance Use Disorder in Past Year: Among People Aged 12 or Older; by Detailed Age Category, Percentages, 2021 and 2022. Accessed January 3, 2024. https://www.samhsa.gov/data/report/2022-nsduh-detailed-tables
    24. Meier P, Seitz HK. Age, alcohol metabolism and liver disease. Curr Opin Clin Nutr Metab Care. 2008;11(1):21-26. doi:10.1097/MCO.0b013e3282f30564
    25. Sklar AL, Gilbertson R, Boissoneault J, Prather R, Nixon SJ. Differential Effects of Moderate Alcohol Consumption on Performance Among Older and Younger Adults. Alcohol Clin Exp Res. 2012;36(12):2150-2156. doi:10.1111/j.1530-0277.2012.01833.x
    26. Boissoneault J, Sklar A, Prather R, Nixon SJ. Acute Effects of Moderate Alcohol on Psychomotor, Set Shifting, and Working Memory Function in Older and Younger Social Drinkers. J Stud Alcohol Drugs. 2014;75(5):870-879. doi:10.15288/jsad.2014.75.870
    27. Barry KL, Blow FC. Drinking Over the Lifespan: Focus on Older Adults. Alcohol Res Curr Rev. 2016;38(1):115-120.
    28. Moore AA, Whiteman EJ, Ward KT. Risks of Combined Alcohol-Medication Use in Older Adults. Am J Geriatr Pharmacother. 2007;5(1):64-74.
    29. Nixon SJ, Prather R, Lewis B. Sex differences in alcohol-related neurobehavioral consequences. Handb Clin Neurol. 2014;125:253-272. doi:10.1016/B978-0-444-62619-6.00016-1
    30. Nolen-Hoeksema S. Gender differences in risk factors and consequences for alcohol use and problems. Clin Psychol Rev. 2004;24(8):981-1010. doi:10.1016/j.cpr.2004.08.003
    31. van Lawick van Pabst AE, Devenney LE, Verster JC. Sex Differences in the Presence and Severity of Alcohol Hangover Symptoms. J Clin Med. 2019;8(6):867. doi:10.3390/jcm8060867
    32. Kirpich IA, McClain CJ, Vatsalya V, et al. Liver Injury and Endotoxemia in Male and Female Alcohol-dependent Individuals Admitted to an Alcohol Treatment Program. Alcohol Clin Exp Res. 2017;41(4):747-757. doi:10.1111/acer.13346
    33. White AJ, DeRoo LA, Weinberg CR, Sandler DP. Lifetime Alcohol Intake, Binge Drinking Behaviors, and Breast Cancer Risk. Am J Epidemiol. 2017;186(5):541-549. doi:10.1093/aje/kwx118
    34. White AM, Castle IJP, Hingson RW, Powell PA. Using Death Certificates to Explore Changes in Alcohol-Related Mortality in the United States, 1999 to 2017. Alcohol Clin Exp Res. 2020;44(1):178-187. doi:10.1111/acer.14239
    35. White AM, Slater ME, Ng G, Hingson R, Breslow R. Trends in Alcohol-Related Emergency Department Visits in the United States: Results from the Nationwide Emergency Department Sample, 2006 to 2014. Alcohol Clin Exp Res. 2018;42(2):352-359. doi:10.1111/acer.13559
    36. Yoon YH, Chen CM, Slater ME, Jung MK, White AM. Trends in Premature Deaths From Alcoholic Liver Disease in the U.S., 1999-2018. Am J Prev Med. 2020;59(4):469-480. doi:10.1016/j.amepre.2020.04.024
    37. Nayak MB, Patterson D, Wilsnack SC, Karriker-Jaffe KJ, Greenfield TK. Alcohol’s Secondhand Harms in the United States: New Data on Prevalence and Risk Factors. J Stud Alcohol Drugs. 2019;80(3):273-281. doi:10.15288/jsad.2019.80.273
    38. Hughes TL, Wilsnack SC, Kantor LW. The Influence of Gender and Sexual Orientation on Alcohol Use and Alcohol-Related Problems. Alcohol Res Curr Rev. 2016;38(1):121-132.
    39. Fish JN. Sexual Orientation-Related Disparities in High-Intensity Binge Drinking: Findings from a Nationally Representative Sample. LGBT Health. 2019;6(5):242-249. doi:10.1089/lgbt.2018.0244
    40. Schuler MS, Collins RL. Sexual minority substance use disparities: Bisexual women at elevated risk relative to other sexual minority groups. Drug Alcohol Depend. 2020;206:107755. doi:10.1016/j.drugalcdep.2019.107755
    41. Gilbert PA, Pass LE, Keuroghlian AS, Greenfield TK, Reisner SL. Alcohol research with transgender populations: A systematic review and recommendations to strengthen future studies. Drug Alcohol Depend. 2018;186:138-146. doi:10.1016/j.drugalcdep.2018.01.016
    42. May PA, Chambers CD, Kalberg WO, et al. Prevalence of Fetal Alcohol Spectrum Disorders in 4 US Communities. JAMA. 2018;319(5):474-482. doi:10.1001/jama.2017.21896
    43. Charness ME, Riley EP, Sowell ER. Drinking During Pregnancy and the Developing Brain: Is Any Amount Safe? Trends Cogn Sci. 2016;20(2):80-82. doi:10.1016/j.tics.2015.09.011
    44. Hoyme HE, Kalberg WO, Elliott AJ, et al. Updated Clinical Guidelines for Diagnosing Fetal Alcohol Spectrum Disorders. Pediatrics. 2016;138(2). doi:10.1542/peds.2015-4256
    45. Williams JF, Smith VC, Committee on Substance Abuse. Fetal Alcohol Spectrum Disorders. Pediatrics. 2015;136(5):e1395-e1406. doi:10.1542/peds.2015-3113
    46. American College of Obstetricians and Gynecologists. Committee on Health Care for Underserved Women. Committee Opinion No. 496: At-Risk Drinking and Alcohol Dependence: Obstetric and Gynecologic Implications. Obstet Gynecol. 2011;118(2):383-388. doi:10.1097/AOG.0b013e31822c9906
    47. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. 2022 National Survey on Drug Use and Health: Table 8.27B – Substance Use in Past Month: Among Females Aged 15 to 44; by Pregnancy Status, Percentages, 2021 and 2022. Accessed January 3, 2024. https://www.samhsa.gov/data/report/2022-nsduh-detailed-tables
    48. England LJ. Alcohol Use and Co-Use of Other Substances Among Pregnant Females Aged 12–44 Years — United States, 2015–2018. MMWR Morb Mortal Wkly Rep. 2020;69. doi:10.15585/mmwr.mm6931a1
    49. Mamluk L, Edwards HB, Savović J, et al. Low alcohol consumption and pregnancy and childhood outcomes: time to change guidelines indicating apparently “safe” levels of alcohol during pregnancy? A systematic review and meta-analyses. BMJ Open. 2017;7(7):e015410. doi:10.1136/bmjopen-2016-015410
    50. Lewis SJ, Zuccolo L, Smith GD, et al. Fetal Alcohol Exposure and IQ at Age 8: Evidence from a Population-Based Birth-Cohort Study. PLOS ONE. 2012;7(11):e49407. doi:10.1371/journal.pone.0049407
    51. Reilly MT, Noronha A, Goldman D, Koob GF. Genetic studies of alcohol dependence in the context of the addiction cycle. Neuropharmacology. 2017;122:3-21. doi:10.1016/j.neuropharm.2017.01.017
    52. Goldman D, Oroszi G, Ducci F. The genetics of addictions: uncovering the genes. Nat Rev Genet. 2005;6(7):521-532. doi:10.1038/nrg1635
    53. Schuckit MA, Smith TL, Rana B, Mendoza LA, Clarke D, Kawamura M. Performance of the Self-Report of the Effects of Alcohol (SRE) Questionnaire Across Sexes and Generations. Alcohol Clin Exp Res. 2019;43(7):1384-1390. doi:10.1111/acer.14038
    54. Schuckit MA, Smith TL. Mediation of effects of the level of response to alcohol and impulsivity 15 years later in 36-year-old men: Implications for prevention efforts. Drug Alcohol Depend. 2017;180:356-362. doi:10.1016/j.drugalcdep.2017.08.030
    55. Schuckit MA, Smith TL, Kalmijn J, et al. Comparison across two generations of prospective models of how the low level of response to alcohol affects alcohol outcomes. J Stud Alcohol Drugs. 2012;73(2):195-204. doi:10.15288/jsad.2012.73.195
    56. Schuckit MA. A Critical Review of Methods and Results in the Search for Genetic Contributors to Alcohol Sensitivity. Alcohol Clin Exp Res. 2018;42(5):822-835. doi:10.1111/acer.13628
    57. King AC, Cao D, deWit H, O’Connor SJ, Hasin DS. The role of alcohol response phenotypes in the risk for alcohol use disorder. BJPsych Open. 2019;5(3):e38. doi:10.1192/bjo.2019.18
    58. King AC, de Wit H, McNamara PJ, Cao D. Rewarding, Stimulant, and Sedative Alcohol Responses and Relationship to Future Binge Drinking. Arch Gen Psychiatry. 2011;68(4):389-399. doi:10.1001/archgenpsychiatry.2011.26
    59. King AC, McNamara PJ, Hasin DS, Cao D. Alcohol Challenge Responses Predict Future Alcohol Use Disorder Symptoms: A 6-Year Prospective Study. Biol Psychiatry. 2014;75(10):798-806. doi:10.1016/j.biopsych.2013.08.001
    60. Zaso MJ, Goodhines PA, Wall TL, Park A. Meta-Analysis on Associations of Alcohol Metabolism Genes With Alcohol Use Disorder in East Asians. Alcohol Alcohol Oxf Oxfs. 2019;54(3):216-224. doi:10.1093/alcalc/agz011
    61. Thomasson HR, Crabb DW, Edenberg HJ, Li TK. Alcohol and aldehyde dehydrogenase polymorphisms and alcoholism. Behav Genet. 1993;23(2):131-136. doi:10.1007/BF01067417
    62. Brooks PJ, Enoch MA, Goldman D, Li TK, Yokoyama A. The Alcohol Flushing Response: An Unrecognized Risk Factor for Esophageal Cancer from Alcohol Consumption. PLoS Med. 2009;6(3):e1000050. doi:10.1371/journal.pmed.1000050
    63. Hurley TD, Edenberg HJ. Genes encoding enzymes involved in ethanol metabolism. Alcohol Res Curr Rev. 2012;34(3):339-344.
    64. Yang SJ, Yokoyama A, Yokoyama T, et al. Relationship between genetic polymorphisms of ALDH2 and ADH1B and esophageal cancer risk: A meta-analysis. World J Gastroenterol WJG. 2010;16(33):4210-4220. doi:10.3748/wjg.v16.i33.4210
    65. Chen CH, Ferreira JCB, Joshi AU, et al. Novel and prevalent non-East Asian ALDH2 variants; Implications for global susceptibility to aldehydes’ toxicity. EBioMedicine. 2020;55:102753. doi:10.1016/j.ebiom.2020.102753
    66. Anthenelli R, Grandison L. Effects of Stress on Alcohol Consumption. Alcohol Res Curr Rev. 2012;34(4):381-382.
    67. Meyers JL, Lowe SR, Eaton NR, Krueger R, Grant BF, Hasin D. Childhood maltreatment, 9/11 exposure, and latent dimensions of psychopathology: A test of stress sensitization. J Psychiatr Res. 2015;68:337-345. doi:10.1016/j.jpsychires.2015.05.005
    68. Kwako LE, Patterson J, Salloum IM, Trim RS. Alcohol Use Disorder and Co-Occurring Mental Health Conditions. Alcohol Res Curr Rev. 2019;40(1):arcr.v40.1.00.
    69. Castillo-Carniglia A, Keyes KM, Hasin DS, Cerdá M. Psychiatric comorbidities in alcohol use disorder. Lancet Psychiatry. 2019;6(12):1068-1080. doi:10.1016/S2215-0366(19)30222-6
    70. Lai HMX, Cleary M, Sitharthan T, Hunt GE. Prevalence of comorbid substance use, anxiety and mood disorders in epidemiological surveys, 1990–2014: A systematic review and meta-analysis. Drug Alcohol Depend. 2015;154:1-13. doi:10.1016/j.drugalcdep.2015.05.031
    71. Debell F, Fear NT, Head M, et al. A systematic review of the comorbidity between PTSD and alcohol misuse. Soc Psychiatry Psychiatr Epidemiol. 2014;49(9):1401-1425. doi:10.1007/s00127-014-0855-7
    72. Chakravorty S, Chaudhary NS, Brower KJ. Alcohol Dependence and Its Relationship With Insomnia and Other Sleep Disorders. Alcohol Clin Exp Res. 2016;40(11):2271-2282. doi:10.1111/acer.13217
    73. Kwako LE, Momenan R, Litten RZ, Koob GF, Goldman D. Addictions Neuroclinical Assessment: A Neuroscience-Based Framework for Addictive Disorders. Biol Psychiatry. 2016;80(3):179-189. doi:10.1016/j.biopsych.2015.10.024
    74. Kwako LE, Schwandt ML, Ramchandani VA, et al. Neurofunctional Domains Derived From Deep Behavioral Phenotyping in Alcohol Use Disorder. Am J Psychiatry. 2019;176(9):744-753. doi:10.1176/appi.ajp.2018.18030357
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    • Identify age, gender, and genetic risk factors for developing AUD.
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    Contributors

    Contributors to this article for the NIAAA Core Resource on Alcohol include the writer for the full article, content contributor to subsections, reviewers, and editorial staff. These contributors included both experts external to NIAAA as well as NIAAA staff.

    External Writer

    Deborah Hasin, MD
    Professor of Epidemiology, College of
    Physicians and Surgeons Department of
    Psychiatry, Columbia University, New York, NY

    NIAAA Content Contributor

    Aaron White, PhD
    Senior Scientific Advisor to
    the NIAAA Director, NIAAA

    External Reviewers

    Anika A. Alvanzo, MD, MS, FACP, DFASAM
    Managing Partner, Uzima Consulting
    Group LLC, Middle River, MD;
    Eastern Region Medical Director, Pyramid
    Healthcare, Inc., Duncansville, PA

    Geetanjali Chander, MD, MPH
    Professor of Medicine, Johns Hopkins
    University School of Medicine, Baltimore, MD

    H. Westley Clark, MD, JD, MPH
    Dean's Executive Professor of Public Health,
    Santa Clara University, Santa Clara, CA

    Kenneth R. Conner, PsyD, MPH
    Professor, Emergency Medicine and
    Psychiatry,
    University of Rochester Medical Center,
    Rochester, NY

    NIAAA Reviewers

    George F. Koob, PhD
    Director, NIAAA

    Patricia Powell, PhD
    Deputy Director, NIAAA

    Bill Dunty, PhD
    Program Director, Division of Metabolism and
    Health Effects and FASD Research Coordinator, NIAAA

    Lorenzo Leggio, MD, PhD
    NIDA/NIAAA Senior Clinical Investigator and Section Chief;
    NIDA Branch Chief;
    NIDA Deputy Scientific Director;
    Senior Medical Advisor to the NIAAA Director

    Aaron White, PhD
    Senior Scientific Advisor to
    the NIAAA Director, NIAAA

    Editorial Team

    NIAAA

    Raye Z. Litten, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Director, Division of Treatment and Recovery, NIAAA

    Laura E. Kwako, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Health Scientist Administrator,
    Division of Treatment and Recovery, NIAAA

    Maureen B. Gardner
    Project Manager, Co-Lead Technical Editor, and
    Writer for the Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    Contractor Support

    Elyssa Warner, PhD
    Co-Lead Technical Editor,
    Ripple Effect

    Daria Turner, MPH
    Reference and Resource Analyst,
    Ripple Effect

    Kevin Callahan, PhD
    Technical Writer/Editor,
    Ripple Effect

    To learn more about CME/CE credit offered as well as disclosures, visit our CME/CE General Information page. You may also click here to learn more about contributors.

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