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Women and Substance Abuse:

A New National Focus

Susan J. Blumenthal, M.D., M.P.A.

INTRODUCTION

Although addictive disorders have been the subject of widespread

concern in the United States, relatively little is known about the causes,

treatment, and prevention of these disorders in women. An estimated

200,000 American women will die of substance abuse-related illnesses

this year—more than four times the number who will die of breast

cancer (extrapolated from National Center for Health Statistics

[1993, p. 46]). The use of tobacco, alcohol, and other drugs and the

improper use of prescription medications are taking a serious toll on

the health and well-being of women and their families. The growing

morbidity and mortality rates from the addictive disorders in women

are preventable tragedies demanding greater attention in research,

service delivery, public policy, and education.

Despite historical evidence to the contrary, U.S. society has generally thought of alcohol and other drug abuse as a problem of men. Yet,

American women have suffered with substance abuse problems for

centuries. Before the Civil War, the number of female drug addicts

outnumbered male substance abusers; in the mid-1800s, 60 to 75 percent

of opium-morphine addicts were women (Cartwright 1982, p. 280).

Although the rate of substance abuse among women today is lower than

that among men, the estimated number of women who use or abuse licit

or illicit substances is of considerable concern, given the prevalence of

this problem and the rising levels of morbidity and mortality associated

with substance abuse (Center for Substance Abuse Treatment 1994).

Former Secretary of Health, Education, and Welfare Joseph Califano

has rightly observed that the magnitude of substance abuse among

women and the full scope of its repercussions have been “masked by

national denial.” If an informed public policy is to be developed to

better understand and combat addictive disorders in women, it is critical

to tear away that mask of denial by evaluating the current status of

addiction research involving women, ranging from etiology to diagnosis
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and from treatment to prevention, throughout the life cycle and across

the diverse racial, ethnic, and socioeconomic characteristics of American women. Gender differences in approaches to diagnosis, intervention, and prevention must be examined, and sex-based differences in the

etiology and treatment of addictive disorders must be addressed. Most

important, prevention and treatment strategies targeted to the unique

needs of women must be developed with cognizance of the unique

biological, psychological, and social factors affecting women’s health.

The urgency of the need to better understand, treat, and prevent

substance abuse was brought into sharper focus at the National Institutes

of Health (NIH) by the reunification of the research components of

the Institutes formerly under the Alcohol, Drug Abuse, and Mental

Health Administration—the National Institute on Alcohol Abuse and

Alcoholism (NIAAA), NIDA, and the National Institute of Mental

Health—into NIH in 1992. This reintegration gave greater prominence

to national research and health care initiatives on substance abuse and

women by more fully integrating the behavioral sciences and the neurosciences into contemporary biomedical research and clinical practice.

Through broadened scientific collaboration and enhanced interdisciplinary program coordination, the behavioral sciences and neurosciences

have increased their prominence and scientific focus within NIH, and

as a result, the study of mental and addictive disorders has found a place

within the nucleus of NIH’s research agenda. After about 25 years,

NIH has finally been reunited with its “head,” rectifying the dichotomy

established long ago by the Greek rational philosophers who split mind

from body. This merger of the Institutes has been a significant step

forward in enhancing the national capacity to understand the causes

and improve the treatment and prevention of all diseases, including the

addictive disorders.

Two other significant developments—health care service delivery

and the education of public and health care professionals—have played

a crucial role in the growing focus on both women’s health and mental

and addictive disorders in the Nation’s research agenda. Over the past

7 years, the Nation has experienced the greatest focus on women’s

health in its history. The year 1990 marked the beginning of a decade

in which women’s health concerns—including mental and addictive

disorders—have received unprecedented attention within the academic and health care communities and in the media. That attention
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continues to grow as science advances, as more women enter the health

professions and attain leadership positions, and as women become

increasingly empowered to take control of their own medical destinies.

During this watershed period, alarming inequities in women’s health

research have come to light, including the failure to include women in

clinical trials; inadequate attention to sex differences in biomedical,

behavioral, and health services research; insufficient funding for research

on women’s health concerns (U.S. General Accounting Office 1990);

and the dearth of women in senior health care professional and scientific

positions in the country’s Federal and academic research institutions

(Blumenthal 1994; Blumenthal 1995, pp. 181-204).

This decade also has been hailed as the “Decade of the Brain”—a

period of unprecedented explosion of research advances in the behavioral sciences and neurosciences resulting in the identification of brain

receptors specific for various neurotransmitters and psychotropic agents;

the localization of genes linked to disease; the mapping of the brain in

both functional and chemical terms; the identification of basic processes

of learning, memory, perception, and sensation; and the elucidation

of mechanisms of behavior change. This tremendous leap forward in

the understanding of the causes of mental and addictive disorders has

resulted in the development of new and effective treatments, helping

to shatter the myths surrounding these illnesses and to soften the stigma

that has been associated with them in the past.

How fitting, then, is the convergence of these two crucial yet

understudied areas that have emerged in this last decade of the

20th century—women’s health and mental and addictive disorders. As

a new national focus on women’s mental health is developed, it is crucial

that it be broad based, spanning the ages of a woman, from birth to old

age; spanning the range of mental and addictive disorders affecting

women; and spanning the spectrum of knowledge gained by working at

the research bench and at the clinical bedside. The challenge to the

mental and addictive disorders research, treatment, and prevention

communities is to better understand and respond to the panoply of

biological and psychosocial factors that contribute to the etiology of

women’s mental and addictive disorders, given the long history of

inequity in how, until recently, medicine and science have approached

women’s health.
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SUBSTANCES OF ABUSE

Whether use of tobacco, caffeine, or alcohol or the illegal use of licit

or illicit drugs—substance abuse is a behavior pattern that has tremendous effects on the Nation, and it is among the most prominent contributors to morbidity and premature mortality in the United States

(National Center for Health Statistics 1994). Although the lifetime

rates of illicit drug use, drug abuse, drug dependence, and alcohol abuse

and dependence are lower for women than for men, nonetheless, the

statistics for women remain sobering. In 1995—

• Nearly one in three women in the United States had used

an illicit drug at least once in her life—33 million out of

110 million women (Substance Abuse and Mental Health

Services Administration 1996). Among women of childbearing

age (15 to 44 years), the rate is approximately 45 percent.

• An estimated 15 percent of all American women ages 15 to 44

are currently abusing alcohol or illicit drugs (Substance Abuse

and Mental Health Services Administration 1996).

• Nearly 5 million women have used an illicit drug at least once in

the past month: 3.6 million had used marijuana; 440,000 had

used cocaine—one-fourth of them in the form of crack; and

nearly 2 million had used an inhalant (Substance Abuse and

Mental Health Services Administration 1996).

• As many as 2.7 million American females older than 12 abuse

alcohol (Substance Abuse and Mental Health Services Administration 1996). Half of all women of childbearing age reported

some alcohol consumption during the previous month (Centers

for Disease Control and Prevention 1997a). In spite of the

increased risk of severe adverse effects in their children from

moderate-to-severe alcohol use during pregnancy, 16 to

21 percent of pregnant women report drinking alcohol during

pregnancy (Substance Abuse and Mental Health Services

Administration 1996; Centers for Disease Control and Prevention 1997a). Because women are more susceptible than men to

the effects of alcohol, moderate drinking for a woman is considered to be less than one drink a day (1.5 ounces of liquor,

5 ounces of wine, or 12 ounces of beer, according to Government

guidelines) compared with no more than two drinks a day for

men (National Heart, Lung, and Blood Institute 1996).
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• In 1994, 1.2 million women had taken prescription drugs for a

nonmedical purpose (National Institute on Drug Abuse 1994).

Three out of five persons admitted to publicly funded treatment

facilities for addiction to tranquilizers and sedatives were women

(National Center for Health Statistics 1996, figure 39).

• Research indicates that more than 4 million women need

treatment for drug abuse (National Institute on Drug Abuse

1994). The National Pregnancy and Health Survey was conducted by NIDA to provide a national estimate of the number of

women who use licit and illicit drugs during pregnancy. Based

on a sample of women who delivered from October 1992 through

August 1993, it was estimated that of the approximately

4 million women who deliver live-born children annually in the

United States, 5.5 percent or 221,000 women are projected to

have used some illicit drug during pregnancy (National Institute

on Drug Abuse 1996).

• Women represent about 25 percent of alcoholism clients in

traditional treatment centers in the United States—a rate

slightly lower than the estimated 30 percent of all alcoholics in

the country who are women (National Institute on Drug Abuse

1990).

• Tobacco use accounts for more than 400,000 premature deaths

in the United States—contributing substantially to deaths from

cancer, cardiovascular disease, chronic lung disease, low birth

weight, mental retardation, and other health problems in infants

born to women who smoked during pregnancy (Centers for

Disease Control and Prevention 1993a, 1993b). More than

80 percent of adult smokers start as teenagers. More than one in

four women smoke cigarettes, and increasing numbers are dying

of smoking-related illnesses (National Center for Health Statistics 1996, figures 4 and 21). Every day in the United States,

3,000 children begin smoking—many of them girls—and onethird will die of their addiction (Institute of Medicine 1994).

Last year 1,700,000 teenage girls reported that they had smoked

at least one cigar (Centers for Disease Control and Prevention

1997b). Lung cancer has become the leading cancer killer of

American women—surpassing breast cancer in 1987 (Centers for

Disease Control and Prevention 1993a, 1993b). Recent studies
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have shown that women are more susceptible than men to the

harmful and addictive properties of cigarettes (Zang and Wynder

1996; Gold et al. 1996; National Cancer Institute 1996; Perkins

1996).

• Approximately 120,000 deaths annually are attributed to the use

of alcohol and illicit drugs (McGinnis and Foege 1993). Female

alcoholics have death rates that are 50 to 100 percent higher

than those of male alcoholics, and more female than male

alcoholics die from suicides, alcohol-related accidents, circulatory disorders, and cirrhosis of the liver (Hill 1982, cited in

National Institute on Alcohol Abuse and Alcoholism 1990).

The costs of addictive disorders are staggering. The annual direct

and indirect costs of drug abuse have been estimated at $66.9 billion;

alcohol abuse raises the total at least another $98.6 billion, and tobacco

adds an additional $72 billion (Center for Substance Abuse Prevention

1993; U.S. Department of Commerce 1992). The Center on Addiction

and Substance Abuse at Columbia University found that substance

abuse and addiction are responsible for a minimum of 20 percent of the

$40 billion medicaid inpatient hospital costs (Health Care Financing

Administration 1997). Moreover, nearly 25 percent of medicare inpatient hospital costs (upward of $20 billion of the $87 billion expended

for this purpose) will cover treatment related to substance abuse and

addictions (Joseph Califano, personal communication, 1994). Other

drug and alcohol use has also been implicated in numerous studies of

other public health problems such as violence against women, motor

vehicle crashes, the transmission of acquired immunodeficiency syndrome (AIDS) and other sexually transmitted diseases, school failure,

unintended pregnancy, low work productivity, homelessness, and suicide

(Center for Substance Abuse Prevention 1994).

WOMEN AND ADDICTION

In this century society has witnessed tremendous changes in

women’s lives and expectations. Women today enjoy educational and

professional opportunities never imagined a generation ago. For the first

time in the Nation’s history, there are more women than men enrolled

in colleges and universities, and more women than men now pursue

graduate study. Women older than age 18 constitute 38 percent of the

total population and 45 percent of the Nation’s work force.
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Women’s average life expectancy has increased by almost 30 years

since the beginning of the century; today, women live, on average,

7 years longer than men (National Center for Health Statistics 1996,

table 29). Although women live longer, they are not necessarily living

better. Women suffer from more chronic illness and greater disability

than men (Office of Research on Women’s Health 1992). They now

face the health problems that accompany long life—osteoporosis,

depression, and Alzheimer’s disease—in greater numbers than men

(Office of Research on Women’s Health 1992).

Insofar as addictions are concerned, the status of research, prevention, and treatment programs for women is limited at best, in part

because this constellation of disorders has long been viewed as the

province of men. Although differences in the bodies and experiences of

men and women are well documented, attention to women’s health has

been neglected in many spheres, particularly in biomedical and behavioral research and in the delivery of treatment services. In addiction

research, as in many other areas of scientific inquiry, many studies simply

were not conducted on female subjects. The majority of studies of

substance abuse among women in the past have centered on the impact

of women’s addiction on children and family life, particularly the effect

on the fetus. These concerns have reflected the traditional view of

women in terms of their reproductive capacity.

Research has neglected examining sex differences in the etiology,

course, treatment, and prevention of these diseases, and this neglect has

led to some alarming statistics and health problems for women:

• Although heart disease is still widely viewed as a “man’s disease,”

it is the number one killer of American women (National Center

for Health Statistics 1996, p. 1, figure 4). Proportionately, more

women than men die of heart disease each year (National Center

for Health Statistics 1996, figure 5). Women are, on average,

10 years older and sicker at diagnosis than men and are more

likely to present with coexisting, chronic conditions. Women

are also more likely than men to die from a heart attack: One

year following a heart attack, three-fourths of men are still alive

compared with just two-thirds of women. In spite of the critical

importance of heart disease for women, much of the research on

preventing heart disease—including smoking prevention—has

been conducted solely on men.
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• When smoking was identified as a major risk factor for illnesses

in men, men alone were targeted in prevention studies to stop

smoking. Today, the rates of lung cancer and other chronic

pulmonary diseases continue to climb among women, whereas

they have begun to decline for men (National Cancer Institute

1996). An estimated 66,000 women will die of lung cancer in

1997—1.5 times the number who will succumb to breast cancer

(American Cancer Society 1997). Smoking-related cardiovascular disease also is on the rise among women, as are the other

health consequences of smoking for women, including increases

in other types of cancer (larynx, esophagus, cervix, and breast),

pulmonary problems, complications of pregnancy and infant

health, osteoporosis, impaired fertility, and earlier onset of

menopause (Burns et al. 1997; Office of Research on Women’s

Health 1992). A number of studies have suggested that women

have less success with smoking cessation efforts than men,

possibly because of fear of weight gain associated with smoking

cessation, reduced social support for smoking cessation, greater

impact of advertising on women, and the increased addictive

properties of nicotine in women (Perkins 1996; Kandel et al.

1994; Centers for Disease Control and Prevention 1995). The

complex psychosocial and biological reasons behind smoking

behavior and smoking cessation in women have not been

evaluated adequately and may complicate efforts to reduce these

alarming statistics.

• As a result of the historical lack of attention to the ways that

diseases manifest in women or can be prevented in women,

women today are the fastest growing group infected with the

human immunodeficiency virus (HIV, the AIDS virus) (Centers

for Disease Control and Prevention 1993c; Karon et al. 1996).

AIDS is now the number one cause of death for women of

reproductive age in several major U.S. cities, and in 1994 it

became the third leading cause of death for American women

between the ages of 25 and 44 (Centers for Disease Control

and Prevention 1996a, 1996b). Teenage girls are closing the

HIV infection gender gap with teenage males at an alarming rate

(Maternal and Child Health Bureau 1996). Again, because

AIDS was thought to be a man’s disease, most prevention,
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detection, and treatment studies targeted men in the past. The

use of illicit substances has played a large role in the transmission

of the AIDS virus to women. Nearly two-thirds of all female

AIDS cases have occurred in women who were either injecting

drug users or were exposed to the AIDS virus through sexual

contact with an injecting drug user (Centers for Disease Control

and Prevention 1997c).

• Young women are not showing the same rate of decrease in

substance abuse as other segments of the population. In fact, in

recent years the use of alcohol and other drugs has been increasing slightly (Johnston et al. 1994; Substance Abuse and Mental

Health Services Administration 1992, pp. 19, 55; National

Center for Health Statistics 1996, table 65). Women who use

drugs often suffer from other serious health problems such as

depression or sexually transmitted diseases. Studies have shown

that an overwhelming majority of female substance users (as

much as 70 percent) have been physically or sexually abused as

children, and many are victims of violence as adults (National

Institute on Drug Abuse 1994).

• At the other end of the age spectrum, older women present

special concerns with respect to substance abuse. Although

alcoholism is lower in this population, the incidence of using

licit medications for other than the intended purpose or ingesting more than the recommended dosages remains high. Elderly

women represent 11 percent of the population, but they are

prescribed more than 25 percent of all written prescriptions—

2.5 times the number prescribed for elderly men (Abrams and

Alexopoulus 1987). Little if any research has been conducted

on this population at risk.

• In part, the greater social sanctions and stigma that drug-using

women face compared with men, including concerns regarding

the loss of custody of their children, have made women less

willing to seek help and treatment for addictive disorders. As a

result, data on the incidence and prevalence of addictive disorders among women—generally on the basis of contacts with

treatment facilities or hotlines—are thought by treatment

experts to severely underrepresent the true magnitude of the

problem (Center for Substance Abuse Treatment 1994).
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• Little awareness exists among health care professionals regarding

the sex-based differences in physiology and cultural environment

that may place women at risk of substance abuse: physical and

sexual abuse, poverty, anxiety and depression resulting from

multiple roles as caregivers and wage earners, issues of poor selfesteem and dead-end employment (or no employment at all),

low educational attainment, and specific life stresses such as

single parenthood, divorce, and loneliness. How these factors

may predispose individuals to substance abuse and what protective factors may exist on the other side of the equation remain

open questions in the research literature.

BUILDING BRIDGES TO RESEARCH ON

ADDICTIONS IN WOMEN: THE NEW

NATIONAL FOCUS ON WOMEN’S HEALTH

Today, a new national focus on women’s health is leading to efforts

to redress past inequities in research, service delivery, and public and

health care professional education that have plagued the fields of

women’s health and addictive disorders. New attention is being paid to

the diseases and conditions that rob women of good mental and physical

health, the development of strategies to keep women healthy, and the

examination of substance abuse as a serious threat to the health of

American women.

U.S. Public Health Service’s Office on Women’s Health

The position of Deputy Assistant Secretary for Women’s Health in

the U.S. Department of Health and Human Services (DHHS) was

established in 1994 to direct the U.S. Public Health Service’s Office on

Women’s Health (PHS OWH), which coordinates DHHS’s efforts to

redress the inequities in research, service delivery, and education that

had put the health of American women at risk.

To that end, PHS OWH stimulates, coordinates, and oversees

research, service delivery programs, and public and health care professional education and training on women’s health care issues across the

agencies of DHHS, including the Agency for Health Care Policy and

Research, Centers for Disease Control and Prevention (CDC), Food

and Drug Administration (FDA), Health Resources and Services
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Administration (HRSA), Indian Health Service (IHS), NIH, and

Substance Abuse and Mental Health Services Administration

(SAMHSA). PHS OWH is undertaking a range of activities in collaboration with these agencies to promote the health of women across their

lifespans, empower women to make informed choices about their health,

and translate research and policy decisions into effective women’s health

programs. PHS OWH also fosters collaborations with other departments

of Government and consumer, scientific, and women’s organizations to

advance women’s health both within the United States and throughout

the world.

PHS OWH works to (1) stimulate the development and implementation of effective women’s health policies and programs at the national,

State, and local levels; (2) strengthen and sustain a broad range of

research on the diseases and conditions that affect women; (3) promote

comprehensive and culturally appropriate prevention, diagnostic, and

treatment services for women across the lifespan; (4) stimulate public

and health care professional education, training, and information

dissemination on women’s health issues; and (5) foster the recruitment,

retention, and promotion of women in scientific careers and in the

health professions. All these efforts are guided by a Public Health

Service Action Plan that has adopted a lifespan approach to issues of

research, health care service delivery, education and training, and career

development in women’s health.

PHS OWH also coordinates the activities of the revitalized PHS

Coordinating Committee on Women’s Health. The committee has

representatives from all DHHS agencies and provides a forum to share

information about women’s health programs across agencies of DHHS.

In addition, regional women’s health coordinators have been designated

in all 10 regions of DHHS. PHS OWH supports a broad range of

women’s health programs and activities to improve the health of women

at the State and local levels.

PHS OWH has also established and supports six National Centers

of Excellence in Women’s Health across the country that provide stateof-the-art comprehensive and integrated health care services, multidisciplinary research, and public and health care professional education

targeted toward the special needs of women. The centers are serving as

national models that can be evaluated and duplicated across the country.
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To ensure that future physicians are trained in women’s health,

PHS OWH has worked in collaboration with NIH, HRSA, the American Medical Women’s Association, and the American Association of

Medical Colleges to expand medical training in women’s health issues,

designing a model curriculum to help medical schools incorporate a new

approach to women’s health into the training of future physicians and

other health care professionals.

One critical issue of focus for PHS OWH is the fight against breast

cancer. PHS OWH coordinates and implements the National Action

Plan on Breast Cancer (NAPBC), a major public/private partnership

dedicated to making significant progress in the battle against this

disease, which will affect one in eight women during her lifetime. The

NAPBC is the product of a national effort, involving citizens, health

care professionals, government representatives, Congress, the media, and

private sector organizations. The Plan serves as a catalyst for building

new knowledge, resources, and commitment to the prevention, diagnosis, treatment, care, and ultimate elimination of breast cancer as a threat

to American women. The NAPBC has also developed a World Wide

Web site (www.napbc.org) that serves as a gateway to Federal and

private sector information and resources on breast cancer.

Furthermore, to enhance the early detection of breast cancer,

PHS OWH has collaborated with the National Aeronautics and Space

Administration, U.S. Department of Defense (DOD), and Central

Intelligence Agency to adapt imaging technologies used in the defense,

space, and intelligence communities to improve the early detection of

diseases in women. The application of several of these new imaging

technologies to breast cancer detection is now being tested in a multisite

clinical trial supported by PHS OWH at major medical centers across

the country.

Another important focus of PHS OWH is the promotion of healthy

behaviors in women across the lifespan. In the year 1900 women died

primarily of infectious diseases and complications of childbirth, on

average, at age 48 (Blumenthal 1995, pp. 181-204). With public health

interventions, such as better sanitation practices and the development

of vaccines and antibiotics, these illnesses have become less of a threat.

Instead, chronic illnesses—heart disease, cancer, lung disease, stroke,

and diabetes, among others—have become the source of the major

health care burden in this country. Behavioral and lifestyle factors—
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smoking, poor diet, lack of exercise, substance abuse, and unsafe sexual

practices—now contribute to more than 50 percent of the causation of

all 10 of the leading causes of death in the United States (McGinnis and

Foege 1993). Research has shown that positive behavior changes

related to the risk factors for these illnesses can prevent seven-tenths of

all premature deaths, two-thirds of all chronic disability, and one-third

of acute illnesses. In addition, changing these health-damaging behaviors can reduce health care costs and enhance the quality of life. The

issues of health and behavior, critical in combating substance abuse, are

central to PHS OWH’s Healthy Women 2000 initiative. This initiative

includes a series of health education conferences and a nationally

syndicated television series that focus on health promotion and disease

prevention strategies for women of all ages; the initiative also has

focused on women and substance abuse.

In addition, PHS OWH has sponsored national leadership conferences on physical activity and women’s health and a college roundtable

series addressing the health concerns of young women. To reflect the

changing demographics of the Nation, PHS OWH has sponsored

conferences on the health concerns of women of color and cosponsored

a post-White House Conference on Aging and Women’s Health to help

increase public awareness about the issues and needs of older women.

PHS OWH is also working to develop the first nationwide osteoporosis

education campaign directed at women across the lifespan. As a response to the need for clear, reliable information on women’s health,

PHS OWH is establishing, in collaboration with DOD, a new National

Women’s Health Information Center. The center will provide consumers, clinicians, and researchers with a user-friendly, single point of access

to thousands of Federal and private sector resources on women’s health

through a toll-free telephone line and the Internet.

Several PHS OWH activities specifically target the problems of

tobacco and illicit drug use by women—starting at a young age, when

most of the risky behaviors begin. In addition to public health initiatives that are designed to make cigarette advertising less appealing and

cigarettes less readily available to children, PHS OWH has targeted girls

and adolescent women, one of the fastest growing segments of the

smoking population. PHS OWH collaborated with the Girl Scouts on a

smoking prevention program—developing an education campaign that

promotes awareness of the dangers of smoking and a new badge that is a
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testament to a no-smoking pledge by Scouts of all ages who wear it.

DHHS’s Smoke-Free Kids and Soccer campaign, in partnership with the

Olympic champions of the U.S. Women’s Soccer Team, also aims

antismoking, educational messages at girls. The DHHS Girl Power!

campaign, launched through SAMHSA, is a major public information

campaign to encourage positive health behaviors (e.g., regular physical

activity, participation in sports) to help delay the onset and reduce the

use of tobacco and illicit drugs and to promote self-esteem in girls

between the ages of 9 and 14.

Additional DHHS Initiatives To Advance Women’s Health

A number of other Federal initiatives have been implemented that

will contribute to the advancement of women’s health in this decade

and into the 21st century. Several DHHS agencies have set in place

special Offices on Women’s Health as internal advocates to advance the

women’s health agenda within the agency’s mandate, and in addition,

each of the DHHS agencies has identified an individual to coordinate

women’s health issues.

Furthermore, the revision of NIH policy requirements to include

women and minorities as research subjects will ensure that these populations are no longer excluded from the conduct of scientific investigation.

Applicants for NIH grants must include women and minorities in

clinical research, unless scientifically unjustified. Applicants who fail to

address this policy may not be funded.

A wide range of institutes and agencies with a stake in the prevention and treatment of substance abuse—NIDA, NIAAA, the National

Cancer Institute (NCI), the National Institute of Neurological Disorders

and Stroke, SAMHSA, FDA, CDC, and IHS, among others—are

undertaking significant initiatives to stimulate research, service delivery,

and prevention programs on women and substance abuse. For example:

• Both NIDA and NIAAA support women’s health-related

research. NIDA is supporting targeted research initiatives on

the use of substance abuse treatment services, consequences of

maternal drug use, and the mechanisms of action of drugs.

NIDA-supported researchers are investigating sex differences

in the etiology, consequences, and behaviors associated with drug

abuse; the prevalence, consequences, and prevention of drug use
27

during pregnancy; and treatment and prevention interventions

related to substance use and AIDS in women. Similarly,

NIAAA is evaluating the effects of alcohol use and abuse among

women and addressing neurobiologic indicators of risk, maternal

and fetal effects of alcohol, treatment protocols, and reproductive health issues. Research findings posit that a complex

interaction of environmental, psychosocial, and biological

factors contribute to the incidence of substance abuse among

women, suggesting that a special emphasis should be placed on

developing treatment and prevention strategies that target

women’s unique needs.

• FDA’s new regulations regarding tobacco sales and advertising

require a photo ID check for anyone younger than 27 who buys

cigarettes or smokeless tobacco. The regulations prohibit the

display of self-service or vending machines for cigarettes in

places accessible to minors. The new regulations also prohibit

tobacco advertising near schools and playgrounds; restrict

advertisements in publications with youth readership to blackand-white text only; and prohibit the sale or giveaway of hats,

t-shirts, or other items identified with a tobacco brand. Furthermore, FDA regulations no longer permit the sponsorship of any

sporting or other event, team, or entry identified with a tobacco

brand.

• CDC has promoted efforts to reduce tobacco use among women

as a component of its overall tobacco control initiative. In

addition to expanding scientific knowledge of the prevalence

and the health effects of tobacco use, implementing national

educational campaigns, and distributing information to the

public on smoking rates, effects, and cessation, CDC also provides funds to the States and the District of Columbia to conduct

tobacco prevention and control programs, including prenatal

smoking cessation programs.

• NCI’s ASSIST Program, one of many NCI programs supporting

sex-specific smoking-related research, funds smoking cessation

programs across the country. The National Institute of Child

Health and Human Development, also at NIH, supports research

on the potential effects of alcohol, tobacco, and other drugs on

fertility, endometriosis, and other reproductive health problems.
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• SAMHSA is the primary Federal agency with responsibility for

the provision of substance abuse and mental health services,

from prevention and early intervention to treatment for those

identified as substance abusers or as suffering from a mental

disorder. SAMHSA’s three centers support a variety of programs

that either target women directly or include women as a priority

population. In collaboration with the Maternal and Child

Health Bureau at HRSA, SAMHSA supports specific community-based demonstration programs to prevent and treat substance use among pregnant and postpartum women. The HighRisk Youth Program, which identifies and reduces factors that

place school-age children at risk for substance use and related

social and psychological difficulties, has placed increasing

emphasis on young women, who previously had been the primary

focus of few programs. Similarly, juvenile and female offenders

now receive priority attention in substance abuse treatment

programs for persons in prison, jail, or community correctional

facilities. SAMHSA has also developed prevention guidelines

for community-based approaches to the reduction of tobacco use

by youth and supports a National Women’s Health Resource

Center that provides information services and community

training on the prevention and treatment of alcohol, tobacco,

and other drug use in women.

HEALTH CARE REFORM

The new national focus on women’s health is beginning to yield

dividends, leading to research advances, new diagnostic techniques, new

treatments, and new ways in which women are being integrated into the

conduct of research and in clinical practice. However, to truly safeguard

women’s health, all American women must have access to comprehensive health care services that include coverage for mental and addictive

disorders—ending discriminatory insurance practices that have denied

or limited coverage for these illnesses in the past.

To this end, new legislation was passed in 1996. President Clinton

signed into law the Kassebaum-Kennedy bill that now protects individuals from losing their health care coverage when they lose or change jobs

and prohibits insurance companies from denying insurance to individuals with preexisting conditions. The bill also contains provisions to
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prohibit discrimination by health insurers against women who have

been victims of domestic violence or who may have a genetic predisposition to various diseases or disabilities. An additional provision of the

law requires that health insurance companies provide the same coverage

for mental illness as for physical disorders, including similar copayments,

deductibles, and annual and lifetime coverage limits.

CONCLUSION

The recent explosion in research advances that has occurred during

this Decade of the Brain has already resulted in new findings that are

increasing the understanding of addiction in women and elucidating sex

differences in the etiology, treatment, and prevention of these disorders.

New research is beginning to shed light on the neuropharmacology of

craving and addictions and on sex differences in drug metabolism and

side effects. At the same time, health services research is beginning to

identify those programs of risk reduction, prevention, treatment, and

rehabilitation that work best for women.

Ezra Pound observed that “hope is a measure of civilization.” Hope

is an important word in addiction medicine. The new national focus on

women’s health and the increased investment in research are bringing

hope for improved detection, treatment, and prevention of addictive

disorders in women.

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AUTHOR

Susan J. Blumenthal, M.D., M.P.A.

Deputy Assistant Secretary for Health (Women’s Health)

Office of Women’s Health

U.S. Department of Health and Human Services

Humphrey Building, Room 730-B

200 Independence Avenue, S.W.

Washington, DC 20201

(202) 690-7650 (Tel)

(202) 401-4005 (Fax)

sblumenthal@osophs.dhhs.gov (E-mail)