The n e w e ng l a n d j o u r na l of m e dic i n e
b o ok r e v ie w s
Women under the Influence
The National Center on Addiction and Substance Abuse
at Columbia University. 292 pp. Baltimore, Johns Hopkins
University Press, 2006. $50 (cloth); $20 (paper).
ISBN 0-8018-8227-3 (cloth); 0-8018-8228-1 (paper).
Alcohol Problems in Adolescents
and Young Adults: Epidemiology,
Neurobiology, Prevention,
and Treatment
Edited by Marc Galanter. 456 pp. New York, Springer-Verlag,
2006. $49.95. ISBN 0-387-29215-2.
W omen under the Influence is a schol-
arly analysis of substance abuse among
American women. This lucidly written book pro-
vides a perceptive and compassionate discussion
of the factors that contribute to the abuse of a wide
spectrum of substances and of the associated so-
cial and health consequences for women.
In the foreword, Joseph A. Califano, Jr., notes
that Some 6 million girls and women abuse or
are addicted to alcohol, 15 million use illicit drugs
and misuse prescription drugs, and nearly 32
million smoke cigarettes. Accurate estimates of
morbidity and mortality associated with alcohol
abuse have been more difficult to obtain than es-
timates for cigarette smoking, and these approxi-
mations are complicated by the fact that heavy
drinking and smoking often occur together. How-
ever, this books estimates of the morbidity and
mortality associated with cigarette smoking are
astounding: Each year, approximately 178,000
women die from a smoking-related disease. More
women die each year in the United States from
lung cancer than from breast, uterine, and ovarian
cancers combined. While the rate of lung cancer
deaths has been declining among men, the rate
has soared by 600 percent among women. Also,
on average, a smoking woman loses 15 years of
her life, while a smoking man loses 13 years.
It is estimated that more than 7.5 million girls
and women misuse or abuse prescription drugs
each year, and women are more likely than men
to become addicted to sedatives, antianxiety drugs,
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or hypnotic agents. Prescription-drug abuse and
illicit-drug abuse, alone or in combination, may
result in death from overdose, suicide, risky sex,
and involvement in violence and criminal activi-
ties. During pregnancy, the continued use of alco-
hol, cigarettes, or prescription or illicit drugs (or
both) can have catastrophic consequences for the
neonate as well as for the mother. The estimated
lifetime cost of caring for a child exposed to to-
bacco, alcohol, or drugs before birth is between
$750,000 and $1.4 million. The eventual social
costs associated with drug-exposurerelated im-
pairment of cognitive skills and with the devel-
opment of conduct disorders are inestimable.
This book thoughtfully examines the myriad
factors that enhance vulnerability to substance-
abuse problems across the life span and the unique
challenges of life-stage transitions in women.
The first chapter, which is entitled Pathways to
Substance Abuse among Girls and Women, offers
a compelling analysis of the effects of direct ad-
vertising of alcohol and cigarettes and the mul-
timedia glamorization of illicit drug use in fash-
ion images, movies, and even the marketing of
perfume. Young people are thought to be espe-
cially vulnerable to media presentations that as-
sociate drug use with pleasure, sex, freedom, lib-
eration, and the ever-elusive but desirable image
of being cool.
A chapter entitled Getting over the Influ-
ence summarizes barriers to treatment and the
limitations of the available types of treatment
programs. A substantial reduction in the prob-
lems associated with substance abuse will re-
quire improved access to treatment and research
to develop more effective treatments. It is impor-
tant for patients and physicians alike to recog-
nize that substance abuse is a chronic disorder,
and like many other chronic medical disorders
such as cardiovascular disease, diabetes, and asth-
ma, it may recur unpredictably and require ad-
ditional treatment. Relapse does not negate pros-
pects for eventual recovery, but it may be part of
the complex process of recovery.
The final chapter of the book, Prevention and
Policy Opportunities across the Life Span, de-
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 The new england journal of medicine
scribes many social, educational, and regulatory
approaches. The authors argue that effective pre-
vention efforts should be tailored to the specific
risks women face at different life stages as well
as to factors universal to women of all ages. They
conclude, Only through effective prevention that
is implemented early and consistently from child-
hood through adulthood, targeting the unique
vulnerabilities of women and capitalizing on key
opportunities for intervention, can we hope to
reduce the problem of substance abuse and the
corresponding need for accessible and affordable
treatment services.
Each chapter is well documented with exten-
sive citations and background notes. Women un-
der the Influence fills an important gap in the lit-
erature, and it is an outstanding contribution to
knowledge about the causes, consequences, and
prevention of substance abuse among American
women across the life span.
The preface to Alcohol Problems in Adolescents and
Young Adults states, Adolescence is already chal-
lenging. The addition of alcohol has only made
it more so. What follows is an excellent review
of alcohol abuse and dependence problems in
young men and women. Recent findings concern-
ing the epidemiology of alcohol abuse and de-
pendence are presented in the first five chapters
of this book. These chapters discuss factors that
may contribute to the induction of alcohol abuse
and dependence among adolescents and college-
age young adults.
The next four chapters describe some neuro-
biologic factors that may be important to consider
in developing strategies to prevent and treat
alcohol use and abuse among adolescents. These
chapters include excellent reviews of the long-
range consequences of drinking during adoles-
cence, the effects of differences in alcohol sensi-
tivity and tolerance during adolescence, the effects
of alcohol on memory and memory-related brain
function in adolescents and adults, and the effects
of alcohol-use disorders on the human brain.
Chapters 10 through 14 focus on the preven-
tion of alcohol problems among adolescents, ado-
lescents in special populations, college students,
and children of alcoholics and other high-risk
groups. These chapters also include a thoughtful
examination of policies to reduce underage drink-
ing. The final five chapters of the book discuss
treatment of coexisting alcohol, drug, and psy-
chiatric disorders as well as assessment-related
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issues in research on the treatment of adolescent
drug abuse.
Lawrence S. Brown, Jr., president of the Ameri-
can Society on Addiction Medicine, comments in
the books preface, It makes sense that effective
remedies to this major public health and societal
challenge would be multifaceted, comprehensive,
and guided by scientific evidence. The scientific
information in this edition provides ample con-
tributions to this effort. The book provides a
comprehensive assessment of alcohol problems
among adolescents and young adults, and it en-
hances our fund of information concerning the
diagnosis, treatment, and ultimately prevention
of alcohol problems in this vulnerable population.
Together with Women under the Influence, it will in-
form policymakers as well as all readers who are
concerned with the care of patients with sub-
stance abuse.
Jack H. Mendelson, M.D.
McLean Hospital
Belmont, MA 02478
jmendel@mclean.harvard.edu
Matters of Substance: Drugs
and Why Everyones a User
By Griffith Edwards. 314 pp. New York, Thomas Dunne
Books, 2005. $24.95. ISBN 0-312-33883-X.
D rawing on his experience accumulat-
ed during a distinguished career research-
ing the worlds ubiquitous drug-abuse problems,
Griffith Edwards attempts in Matters of Substance
to summarize the essence of the relationship be-
tween humankind and addictive substances, with
the aim of suggesting a way forward. The result
is a rather idiosyncratic tour dhorizon that provides
a serviceable introduction for the general reader
and gives a few insights for the specialist, with a
closing trajectory that highlights the intractabil-
ity of the issue.
Using the schema developed in Norman Zin-
bergs important work Drug, Set, and Setting: The
Basis for Controlled Intoxicant Use (New Haven, Conn.:
Yale University Press, 1984), Edwards eschews
the essentialist position which largely under-
pins control legislation that a given drug pro-
duces similar effects in all humans under all cir-
cumstances. Instead, he situates the effects of
drug use within the social milieu as well as within
www.nejm.org may 25, 2006