(Lee Powell/The Washington Post)

UNNATURAL CAUSES | SICK AND DYING IN SMALL-TOWN AMERICA: Since the turn of this century, death rates have risen for whites in midlife, particularly women. In this series, The Washington Post is exploring this trend and the forces driving it.

The ads started popping up about a decade ago on social media. Instead of selling alcohol with sex and romance, these ads had an edgier theme: Harried mothers chugging wine to cope with everyday stress. Women embracing quart-sized bottles of whiskey, and bellying up to bars to knock back vodka shots with men.

In this new strain of advertising, women’s liberation equaled heavy drinking, and alcohol researchers say it both heralded and promoted a profound cultural shift: Women in America are drinking far more, and far more frequently, than their mothers or grandmothers did, and alcohol consumption is killing them in record numbers.





White women are particularly likely to drink dangerously, with more than a quarter drinking multiple times a week and the share of binge drinking up 40 percent since 1997, according to a Washington Post analysis of federal health data. In 2013, more than a million women of all races wound up in emergency rooms as a result of heavy drinking, with women in middle age most likely to suffer severe intoxication.

This behavior has contributed to a startling increase in early mortality. The rate of alcohol-related­ deaths for white women ages 35 to 54 has more than doubled since 1999, according to The Post analysis, accounting for 8 percent of deaths in this age group in 2015.





“It is a looming health crisis,” said Katherine M. Keyes, an alcohol researcher at Columbia University.

Although federal health officials and independent researchers are increasingly convinced that even moderate drinking poses health risks, American women are still receiving mixed messages. Parts of the federal government continue to advance the idea that moderate drinking may be good for you. The National Institute on Alcohol Abuse and Alcoholism, a division of the National Institutes of Health, is overseeing a new $100 million study, largely funded by the alcohol industry, that seeks to test the possible health benefits of moderate drinking.

Meanwhile, many ads for alcohol — particularly on social media — appear to promote excessive drinking, which is universally recognized as potentially deadly. These ads also appear to violate the industry’s code of ethics, according to a Post analysis of alcohol marketing.

For example, when girl-power heroine Amy Schumer guzzled Bandit boxed wine in the movie “Trainwreck,” Bandit’s producer, Trinchero Family Estates, promoted the scene on social media. Young women responded with photos of themselves chugging Bandit. Within months, Trinchero said, sales of boxed wines — sometimes called “binge in a box” — jumped 22 percent.

“We saw it first with tobacco, marketing it to women as their right to smoke. Then we saw lung cancer deaths surpass deaths from breast cancer,” said Rear Adm. Susan Blumenthal, a former U.S. assistant surgeon general and an expert on women’s health issues. “Now it’s happening with alcohol, and it’s become an equal rights tragedy.”

Alcohol marketing is regulated primarily by industry trade groups, but dozens of studies have found lapses in their record of enforcing the rules. As a result, an international group of public health experts convened by the World Health Organization’s regional office in Washington, D.C., plans to call in January for governments worldwide to consider legislation similar to laws adopted a decade ago to sharply curtail tobacco advertising.

“The industry’s system of self-regulation is broken,” said Thomas F. Babor, a professor at the University of Connecticut School of Medicine who is aiding the effort. “The alternatives are clear: Either you have to take their system and put it into independent hands, or you have to go with a partial or full legal ban on alcohol marketing.”

[Nine charts that show how white women are drinking themselves to death]

Officials with the Distilled Spirits Council of the United States (DISCUS), one of the largest U.S. trade groups, defend their record of oversight, saying it has received high marks from federal regulators.

“The Council’s Code of Responsible Practices sets more stringent standards than those mandated by law or regulation, or that might be imposed by government due to First Amendment constraints,” council Senior Vice President Frank Coleman said.

DISCUS tells members that ads should not “in any way suggest that intoxication is socially acceptable conduct.” The Beer Institute tells members that their “marketing materials should not depict situations where beer is being consumed rapidly, excessively.” And the Wine Institute prohibits ads that make “any suggestion that excessive drinking or loss of control is amusing or a proper subject for amusement” or that directly associate use of wine with “social, physical or personal problem solving.”

But these rules appear regularly to be flouted, particularly on alcohol companies’ websites and ­social-media feeds, which are soaking up a growing share of the more than $2 billion the industry is expected to spend on advertising this year. And the trade groups acknowledge that they do not investigate or act on possible violations unless they receive a formal complaint.



A woman samples a bottle of wine at a festival in Raleigh, N.C. Companies are gearing promotions to target women, with much of the edgiest marketing appearing on social media. (Bonnie Jo Mount/The Washington Post)

Normalizing drinking

Some of the edgiest ads appear on social media — Facebook, Twitter, Instagram — where they can be narrowly targeted toward the inboxes of the most eager consumers.

“They can be very specific,” Facebook spokeswoman Annie Demarest said. “The ads could go to married women ages 21 to 60 who read about wine and leisure. They can also target the ads based on location, interests, demographics, behaviors and connections.”

Jokes about becoming inebriated are common. One Twitter ad features a woman with a bottle the size of a refrigerator tilted toward her lips. Its contents: Fireball Cinnamon Whisky.

Women also are frequently shown drinking to cope with daily stress. In one image that appeared on a company website, two white women wearing prim, narrow-brimmed hats, button earrings and wash-and-set hair confer side by side. “How much do you spend on a bottle of wine?” one asks. The other answers, “I would guess about half an hour . . . ” At the bottom is the name of the wine: Mommy’s Time Out.

Another ad on a company website features a white woman wearing pearls and an apron. “The most expensive part of having kids is all the wine you have to drink,” it says above the name of the wine: Mad Housewife.

This spring, Mad Housewife offered a Mother’s Day promotion: a six-pack of wine called Mommy’s Little Helper.



Mommy’s Time Out and Mad Housewife are two wines that are marketed toward women. (Bonnie Jo Mount/The Washington Post)

The trend extends to ­wine-related housewares. A flask promoted on the Mad Housewife site features two women from the “Mad Men” era asking, “Who is this ‘Moderation’ we’re supposed to be drinking with?”

An ad on the Etsy marketplace website promotes a stemmed glass big enough to hold an entire bottle of wine with the line: “She will be telling the truth when she says ‘I only had 1 glass.’ ” And Urban Outfitters — a retailer that markets to 18- to 28-year-olds — stocks whole-bottle wine glasses that say: “Drink until your dreams come true” and “This is how you adult.” Urban Outfitters did not respond to calls and emailed messages.

Alcohol marketing experts see a feedback loop between alcohol advertising and popular culture. They cite Trinchero’s repurposing of Schumer’s scene in “Trainwreck” as a prominent example.

“The rise in hazardous drinking among women is not all due to the ads. But the ads have played a role in creating a cultural climate that says it’s funny when women drink heavily,” said Jean Kilbourne, who has produced several films and books about alcohol marketing to women. “Most importantly, they’ve played a role in normalizing it.”

Multiple experts on alcohol marketing said Trinchero’s use of the scene to promote its wine violated industry standards.

Wendy Nyberg, Trinchero’s marketing vice president, defended the company’s behavior, saying Trinchero officials had no role in the production of “Trainwreck” and no control over how their wine was portrayed. It’s “easier when you control the messaging,” she said, adding: “We have to promote moderation in everything that we do. We stick to the code of ethics.”

The owner of Mommy’s Time Out did not respond to requests for comment, and marketing promotions sent to the company for a response have been removed from the company’s public Facebook page.

Damian Davis, the owner of the Seattle-based Rainier Wine, which produces Mad Housewife, said he does not think his ads crossed a line.

“We treat wine like a lifestyle product. I grew up in a big Catholic family, and having it with dinner was a way of life,” Davis said. “I certainly don’t encourage binge drinking. It certainly is a drug, and it can be dangerous.”

Even responsible drinking campaigns can send conflicting messages. A Facebook ad for Smirnoff Ice — ranked among the five most popular beverages by young female drinkers — shows a stack of caps from four pint-size bottles. The tagline: “Know Your Limit.”





“That’s binge drinking,” said David Jernigan, who runs the Center for Alcohol Marketing and Youth at the Johns Hopkins Bloomberg School of Public Health in Baltimore. Jernigan, who advocates limits on alcohol marketing and has come under frequent attack from the alcohol industry, uses the Smirnoff ad in a presentation he calls “Virginia Slims in a Bottle.”

“Not only is that not responsible drinking,” he said. “That’s hazardous drinking.”

In a statement, Diageo, the maker of Smirnoff Ice, defended the ad, saying that by “saving the bottle caps, you keep track of how much you have had. Each individual has their own individual limits and for each individual these limits can vary based on time period of consumption, food intake and many other factors.”

Officials with Fireball Whisky declined to comment.

‘No gender equity’

As it happens, drinking can be especially hazardous for women.

Women tend to have smaller bodies than men, and differences in physiology that make blood-alcohol­ levels climb faster and stay elevated longer. Some studies have found that women have lower levels of the stomach enzymes needed to process the toxins in alcoholic beverages.

As a result, according to the Centers for Disease Control and Prevention, women are more prone to suffer brain atrophy, heart disease and liver damage. Even if a woman stops drinking, liver disease continues to progress in ways it does not in men, said Gyongyi Szabo, a professor at the University of Massachusetts Medical School. And research definitively shows that women who drink have an increased risk of breast cancer.

“There is no gender equity when it comes to the effects of alcohol on men versus women,” Szabo said. “Females are more susceptible to the unwanted biological effects of alcohol when they consume the same amount of alcohol and at the same frequency — even when you adjust for weight.”

Many women don’t know this — nor do they understand what constitutes excessive drinking, said Robert D. Brewer, leader of the CDC’s alcohol program. For women in the United States, anything more than one drink a day is considered excessive. That’s one ounce of distilled spirits, 12 ounces of beer or five ounces of wine.

Four drinks consumed within two hours is considered binge drinking. That’s about two-thirds of a bottle of wine.

“Most people do not understand what binge drinking looks like, and they don’t yet recognize how dangerous it is,” Brewer said. “Smoking, eating unhealthy foods, not exercising — people get what that can do to your health. But we are in a way different stage with binge drinking.”



Women sample and drink wine at a festival in Raleigh, N.C. Women consume the majority of wine in the United States. (Bonnie Jo Mount/The Washington Post)

The alcohol industry and some government agencies continue to promote the idea that moderate drinking provides some health benefits. But new research is beginning to call even that long-standing claim into question.

This year, Jennie Connor, a professor at the University of Otago Dunedin School of Medicine in New Zealand, published a paper that found “strong evidence” that drinking as little as two servings of alcohol a day can cause cancer at seven sites in the body — mostly in areas where human cells come in direct contact with alcohol. Connor’s research included a survey of dozens of studies of the issue by prominent organizations, including the World Cancer Research Fund, the American Institute for Cancer Research and the International Agency for Research on Cancer.

In an earlier paper examining alcohol and cancer in the New Zealand population, Connor found that about a third of alcohol-related cancer deaths among women were associated with less than two standard drinks per day.

About the time this work was appearing, DISCUS chief scientist Samir Zakhari produced research casting doubt on its validity.

Zakhari also wrote an opinion piece directly attacking Connor’s study, using earlier research to dispute her findings.

Connor fired back at Zakhari in an op-ed published in a New Zealand newspaper, noting that Zakhari relied on — and misrepresented — her own earlier research. “The author cites Health Promotion Agency research showing how wrong I am,” she wrote. “If he had opened the report, he would have discovered that I wrote it.”

Zakhari scheduled and then canceled an interview with The Post to discuss his criticism of Connor and other alcohol researchers.

“I occasionally write op-eds or letters to the editor, most often in response to news coverage that contains flawed science,” he ultimately said in a statement.

The CDC’s Brewer, however, said that Connor’s research — and other recent work highlighting the health risks of drinking — is persuasive.

“The current and emerging science does not support the purported benefits of moderate drinking,” Brewer said. “The risk of death from cancer appears to go up with any level of alcohol consumption.

“The guidelines talk about low-risk consumption, but there is no such thing.”

Julie Tate contributed to this report.