Heavy drinking has become a bigger, more socially accepted part of American women's lives. And health statistics show the results have been deadly.
"Alcohol is killing twice as many middle-age women as 18 years ago," said Kristie Gerrells, a licensed addiction counselor and clinical supervisor at the Red River Behavioral Health System in Grand Forks.
"We have more understanding of why that takes place. Women have an extra predisposition to health problems stemming from alcohol abuse, due to their physiology," she said.
Since 2000, death rates have risen for whites, particularly women, in midlife, according to a recent analysis by the Washington Post of Centers for Disease Control mortality rates.
The study found women engaging in dangerous habits, including binge drinking, drinking more than once a week and being treated in emergency rooms for problems related to heavy drinking.
Other alcohol-related factors may be contributing to the climbing death rates, said Sharon Wilsnack, UND Chester Fritz distinguished professor of psychiatry and an internationally recognized researcher of problem drinking in women.
"We know, for example, that alcohol is linked to suicide," she said. "The opioid epidemic may also be a factor-that's a really dangerous combination."
She also cited the possibility that traffic accidents may be boosting the alcohol-related death rate of women, more of whom are driving themselves, she said.
In Grand Forks County, the death rate for white women has increased 85 percent since 1999, according to the CDC. The current rate of 231 deaths per 100,000 people is in the highest one-third of the state and the nation.
The way women's lives have changed over the years may explain the rising death rate, to some degree, Wilsnack said.
Decades ago, it was "unusual" for a women to have roles beyond that of wife and mother, she said. "Now, you are supposed to do it all-have kids, a job and be a perfect parent and perfect entertainer.
"It's more normal now for women to have multiple roles and, if not, there's pressure to have multiple roles or to do it perfectly."
Alcohol may become an inviting antidote to those pressures.
The "normalization" of drinking is evident, for example, in the behavior of young mothers who plan play dates for their kids, Wilsnack said.
"They bring bottles of wine and sip wine while watching their kids play in the park," she said. "Alcohol is becoming a part of a lot of different interactions."
Websites, such as "Moms Who Need Wine," reflect a growing social media phenomenon that makes light of young, stressed-out mothers who need to put their feet up. For example, they can buy novelty socks that convey their plight-the foot of one sock imprinted with, "If you can read this" and on the other, "bring me a glass of wine."
Other sites show images of a bottle-size glass of wine coupled with the phrase, "I just had one glass."
Zoe Flaten, 23, a recovering alcoholic who lives in Grand Forks, said she has seen "lots of things" that attest to drinking, such as T-shirts that read, "This mom needs a glass of wine" or water bottles imprinted with "This may contain alcohol."
She views it as messaging that is, at the least, unhealthy.
"Just in our community alone, binge drinking is seen as normal," Flaten said. "It's normal to black out and be completely obliterated-to drink to get drunk and not for leisure. It's social; that's what activities are based on around here."
More dangerous for women
Excessive drinking in women is also dangerous because women are physiologically different from men, health care professionals say.
"Women are more susceptible because of the way we're made," Gerrells said. "We metabolize alcohol at a different rate than men.
"Women tend to weigh less than men and, pound for pound, a woman's body contains less water and more fatty tissue than a man's. Because fatty tissue retains alcohol, alcohol remains at higher concentrations for longer periods of time in the woman's body, exposing her brain and organs to more alcohol.
"Women also have a smaller amount of enzymes, in general, than men," Gerrells said. "These enzymes break down alcohol in the stomach and liver. We absorb more alcohol in the bloodstream because we have lower levels of these enzymes."
In a career that spans more than 20 years, Gerrells has seen an increase in the proportion of women who seek help for problem drinking.
"I noticed early in my career, in the mid- to late-'90s at treatment facilities, the majority of patients were male," she said. "That has changed. It's become understandable that women can reach out for help."
The ratio of men to women has moved closer to 50-50 in the past five years, she said.
Many factors-including emotional, mental and family predisposition-can contribute to women's abuse of alcohol, Gerrells emphasized. "Those are separate, compounding factors."
"Women may be on multiple medications, and medications can damage the liver," she said. "The liver has a very big job, filtering toxins and waste, including medications.
"When you look at death rates of women (due to alcohol use) you have to factor in what else they are ingesting."
And when it comes to social drinking, some women probably don't understand what binge drinking is, Gerrells said.
Binge drinking is defined as consuming four drinks within two hours.
"Some women do, but whether they realize it or not, it's happening."
"I don't think women understand the seriousness or the risk of binge drinking," she said. "They think of it as funny, to get really drunk."
While pharmaceutical advertising includes information on potential risks, Flaten wonders why alcohol advertising does not, she said.
"They spend so much time trying to get people to stop smoking, why isn't there more focus on the risk factors of drinking, on what it can do to you?"
Ethics in alcohol ads
Wilsnack said she is skeptical about how well the industry complies with its rules against promoting heavy drinking in advertising, especially since no action is taken without a formal complaint being filed.
Wilsnack, who has been studying problem drinking in women since the early 1980s, served for 10 years on the review committee, and five years on the board of trustees, of the Alcoholic Beverage Medical Research Foundation, she said.
She and her colleagues who also are involved in alcohol-abuse research funded by the National Institutes of Health and other agencies share evidence of questionable marketing practices.
"I have seen awful examples of violations of ethics," Wilsnack said, describing some magazine ads as "pornographic."
"Apparently nobody complains," she said.
The liquor industry "is failing at self-regulation, but it's something worth working on," Wilsnack said. "I know there are ethical people in the industry who genuinely believe most people could use their products responsibly. ... (But they) could find creative ways to monitor advertising.
"Reacting to formal complaints is not a likely way of identifying problem ads."
Wilsnack sees similarities between the marketing of alcohol to women in recent years to the cigarette industry's targeting of women decades ago.
"In my college years (the 1970s), smoking was considered very sophisticated," she said. "The Virginia Slims ads were saying, 'You've come a long way, Baby.' ... It's the whole idea that we can do anything the guys can do."
That approach is replicated in some liquor industry marketing efforts.
"The idea of empowerment and gender equality is a big part of it," Wilsnack said.
She's seen websites where women brag about drinking, "like, 'Look what I can do,'" that promote excessive drinking, she said. "Women send in videos of themselves and their friends. They're just drunk, throwing up, half-naked-as if to say, 'We can be just as gross and disgusting as the guys' or 'Wow, isn't this cool?'"
If gender equality is driving more women to drink excessively, maybe things can and will change, Wilsnack said.
"If that's one of the major dynamics, maybe that will all burn out and smart young women are going to figure out alcohol use will not lead to success," she said.
"Hopefully, this will be somewhat of a passing pattern, and young women will realize it's not smart to drink in an out-of-control way."