Can alcohol policy prevent harms to women and children from men’s alcohol consumption? An overview of existing literature and suggested ways forward

Abstract

The World Health Organization’s list of cost-effective alcohol control policies is a widely-used resource that highlights strategies to address alcohol-related harms. However, there is more evidence on how recommended policies impact harms to people who drink alcohol—such as physical health problems caused by heavy alcohol use—than on secondhand harms inflicted on someone other than the person drinking alcohol, i.e., alcohol’s harms to others. In this essay, we describe evidence of impacts of alcohol policy on harms to women and children resulting from men’s alcohol consumption, as well as options for making policies more relevant for reducing intimate partner violence and child abuse. We begin with an overview of harms to women and children resulting from men’s alcohol consumption and review cost-effective alcohol policies with potential to reduce these harms based on likely mechanisms of action. Next, we present a rapid review of reviews to describe existing evidence of impacts of these policies on the outcomes of physical violence, sexual violence, and child abuse and neglect. We found little evidence of systematic evaluation of impacts of these important alcohol policies on harms to women and children. Thus, we advocate for increased attention in evaluation research to the impacts of alcohol policies on harms experienced by women and children who are exposed to men who drink alcohol. We also argue for more consideration of a broader range of policies and interventions to reduce these specific types of harm. Finally, we present a conceptual model illustrating how alcohol policies may be supplemented with other interventions specifically tailored to reduce alcohol-related harms commonly experienced by women and children as a result of men’s alcohol use.

Introduction

Most research on alcohol is framed in terms of documenting and understanding effects of alcohol consumption upon disease morbidity and mortality of the drinker (Laslett & Room, 2021). This individually focused framing fails to account for the diverse ways in which other people—and entire communities—can be affected by another person’s alcohol consumption (Room et al., 2010). As such, the economic and social burden of alcohol may be greatly underestimated (Jiang et al., 2022). Men drink more than women in all societies—53.6% of men globally are current drinkers vs. 32.3% of all women (World Health Organization [WHO], 2018)—and male drinkers are more likely than female drinkers to cause harm to others (Laslett & Cook, 2019; Laslett, Jiang, et al., 2020; Laslett et al., 2019; Wilsnack et al., 2000). Consideration of the broader impacts of alcohol consumption could highlight different elements of the burden of alcohol, particularly for women and children (Laslett & Cook, 2019; Laslett et al., 2017; Stanesby et al., 2018).

Alcohol control policies are key levers to reduce societal harms, including harms experienced by women and children (Babor et al., 2023). However, we have relatively limited data on the impacts of specific alcohol policies on harms to women and children (Laslett & Room, 2021; Room et al., 2022). In this essay, we summarize extant evidence on harms experienced by women and children from men’s alcohol use; describe results of a rapid review of the impacts of recommended cost-effective alcohol policies on harms to women and children from men’s drinking; explore options for making policies and their evaluations more relevant to and inclusive of these harms; and advocate for a comprehensive policy approach that takes alcohol’s harms to others into consideration.

Overview of Harms from Men’s Alcohol Use Experienced by Women and Children

Men drink about three-quarters of the alcohol consumed in the world, and male alcohol consumption is particularly predominant in low- to middle-income countries, where men account for more than four-fifths of the alcohol consumed and men experience more personal harms, such as health conditions caused by chronic alcohol consumption as well as acute harms such as alcohol-involved injury (GBD Collaborators & Ärnlöv, 2020; WHO, 2018). However, men’s drinking also negatively affects women and children. Harms caused by men’s alcohol use include intimate partner violence (IPV) (Abramsky et al., 2011; Cafferky et al., 2018; Graham et al., 2011; Laslett, Graham, et al., 2021; Leonard & Quigley, 2017), reduced educational opportunities (Laslett & Cook, 2019), and financial deprivation (Laslett, Jiang, et al., 2020; Laslett, Mojica-Perez, et al., 2021). Physical abuse or family violence–related harms to children are significantly greater (more than fourfold) in households where someone drinks alcohol excessively, and a man is most likely to be identified as a household’s excessive drinker (Laslett, Stanesby, et al., 2020). Controlling behaviors, financial abuse, conflict, and erratic behaviors all escalate when a perpetrator is intoxicated, craving, or in withdrawal from alcohol (Gilchrist et al., 2019; Radcliffe et al., 2021). In a study of eight countries (Laslett et al., 2017), 4% to 14% of all families reported harm to children—verbal abuse, neglect, physical harm, or family violence—because of someone’s heavy alcohol consumption. Globally, harms caused by family members’ and partners’ alcohol use are associated with poor mental health and reduced quality of life for others in the family (Callinan et al., 2019; Karriker-Jaffe et al., 2018; Stanesby et al., 2018). Thus, the extent of harms experienced by women and children from men’s drinking and their reduced well-being and lower quality of life (Laslett & Cook, 2019) highlight the need for alcohol policies and interventions that focus specifically on preventing these harms.

How Alcohol Policy Can Reduce Harms to Women and Children

Policy intervention to protect women and children from harms caused by men’s alcohol use has a long history. Male alcohol use and intoxication were recognized as a significant social problem by 19^th-century women’s movements (Schrad, 2021; Tyrrell, 2013). These movements drew public attention to the impact on women of living with violence, instability, and financial hardship resulting from their husbands’ alcohol use (Murdock, 2002), and lobbied for restrictions on the supply of alcohol through trading-hours limitations, Sunday closings, and alcohol-free (“dry”) areas (Pleck, 1987). Despite these historical roots and decades of evidence showing alcohol to be a risk factor for violence (Abramsky et al., 2011; Cafferky et al., 2018; Stith et al., 2004), alcohol’s role in certain harms has sometimes become a contested issue. For example, because alcohol can be used to excuse perpetrators or diminish their accountability for violence (Radcliffe et al., 2021), IPV researchers have been reluctant to focus on alcohol’s role in violence (Heise, 2008). In this essay, we take a public health approach (Karriker-Jaffe et al., 2018) to examine impacts of alcohol policy on a variety of harms to women and children from men’s alcohol use, including but not limited to physical violence.

WHO has recommended several cost-effective policy interventions for reducing alcohol-related harms. These include increasing alcohol taxes and prices, reducing physical availability of retailed alcohol, and banning or comprehensively restricting exposure to alcohol advertising (WHO, 2018). Overall, taxation and pricing strategies reduce alcohol-related mortality and morbidity from conditions ranging from liver cirrhosis to violence to sexually transmitted infections (Babor et al., 2023). Recently, minimum unit pricing has been introduced in a few countries and found effective for reducing alcohol-related harms (Maharaj et al., 2023). Recommended strategies for reducing availability of alcohol include regulating density of alcohol outlets, limiting hours and days of retail alcohol sales, and establishing or raising the legal age to purchase alcohol. Very few places (primarily some Islamic countries) have implemented total marketing bans across all media types, but such bans have been found to be effective when paired with adequate enforcement (e.g., Rossow, 2021a; Rossow, 2021b). These cost-effective policies are relatively inexpensive and easy to implement once adopted, although the process leading to policy adoption is not always smooth. For example, mustering political will to raise alcohol taxes can be difficult. WHO has drafted an action plan to advance implementation of the global strategy to reduce the harmful use of alcohol (WHO, 2022b), and this plan includes activities to help achieve increased implementation and enforcement of high-impact, cost-effective policies.

Highly cost-effective policies focus primarily on reducing alcohol consumption and harms experienced by someone who drinks alcohol. Theoretically, by reducing alcohol consumption, these policies should also reduce alcohol-related harms experienced by people other than the drinker, including women and children exposed to men’s alcohol use, and there is some evidence of this (e.g., Kowalski et al., 2023). However, some impacts of these policies may not be positive when we consider harms to others resulting from men’s alcohol use. For example, higher alcohol prices or restrictions on hours and days of sale in licensed on-premise venues may reduce problems in licensed premises; however, these policies could also shift alcohol consumption into private homes, which could then increase harm to women and children. In contrast, restrictions or bans on advertising alcohol may reduce alcohol consumption by changing norms and beliefs about drinking and intoxication, which may help reduce harms both to people who drink alcohol and to others.

Review of Evidence of Policy Impacts on Harms to Women and Children

We conducted a rapid review of reviews to examine harms to women and children from someone else’s alcohol use as target outcomes and identify focal mechanisms in published alcohol policy studies. Using the definition adapted by Tricco et al. (2015), we consider a rapid review to be “a type of knowledge synthesis in which components of the systematic review process are simplified or omitted to produce information in a short period of time” (p. 2). This allows for a more structured review of the literature while being realistic about scope and resources (Khangura et al., 2012; Tricco et al., 2015). As such, we used “streamlined” methods (Tricco et al., 2015) for our rapid review, including limiting our search to one widely available database (PubMed) and restricting the search to peer-reviewed publications written in English. Our list of specific search terms was adapted from Wilson et al. (2014), as we determined they had comprehensively searched and evaluated the alcohol policy and harms literature prior to 2012. The adaptation of terms for our search included the focus on “alcohol policy” and “reviews” (systematic, critical, scoping). We screened identified abstracts for measures of policy impacts on specific harms, which included but were not limited to IPV, child abuse, child maltreatment, and assault. Reviews were not limited by year of publication. Reviews were excluded if they did not describe an alcohol policy and its impacts on one of these outcomes, with assessment of harms both before and after a policy was introduced or changed. While this was not a comprehensive systematic review, our search strategies identified a broad literature for consideration. We did not systematically de-duplicate primary studies in our rapid review of reviews; however, we did a hand-search to identify duplicate studies for specific outcomes to better understand the breadth of the literature to date.

Primary Policy Variables and Key Outcomes in the Extant Literature

We identified 29 reviews that (1) focused on at least one of the focal policies (enacting and enforcing increased prices or alcohol excise taxes, restrictions on physical availability of alcohol, and bans or comprehensive restrictions on alcohol advertising) and also (2) included any coverage of harms to women and children resulting from men’s drinking. Studies included in the reviews were overwhelmingly from high- and middle-income countries, especially North America, northern Europe, and Australasia (see Online Supplemental Table S1); several review authors commented on the lack of published evidence from low-income and lower-middle-income countries.

Overall, most primary outcomes presented in the reviews pertained to alcohol consumption, rather than harms to women or children resulting from men’s alcohol use. When alcohol’s harms to others were included in reviews, typical outcomes were violence-related. Most data in these studies came from police- or hospital-reported assaults or family violence incidents, with a few studies using child protection records, self-report data, or behavioral surveys. Eight reviews included both IPV and child abuse/neglect outcomes; eight other reviews included intimate partner, domestic, and/or dating violence only; and one review included child abuse or neglect only. We identified a limited literature on alcohol policy and child abuse/maltreatment: Two primary studies with multiple publications (Freisthler et al., 2007; Freisthler et al., 2008; Freisthler et al., 2006; Markowitz & Grossman, 1998; Markowitz & Grossman, 2000) were included in several identified reviews. Twelve reviews discussed assault or violence generally, which may have included harms to women and children, but data were not disaggregated by who was affected (e.g., Roodbeen et al., 2021; Taylor et al., 2020). One review focused on gender in studies of alcohol-related harms (Fitzgerald et al., 2016) and concluded “gender is poorly reported in systematic reviews of population-level interventions to reduce alcohol-related harm” (p. 1735). Table 1 provides a snapshot of the findings from 11 selected reviews that provided the most complete descriptions of independent variables (alcohol policy), dependent variables (harms to women and children), and mechanisms of policy action (mediators).

Table 1.

Highlights of select reviews addressing policy impacts on harms to women and children

Review Article	Description
Baldwin et al. (2022)	Systematic review of 31 studies on effects of alcohol supply reduction policies on children and adolescents • Policies: minimum legal drinking age (MLDA), trading restrictions (hours), taxation • Outcomes: alcohol-related hospitalizations, emergency department presentations, child protection orders, mental health–related outcomes • Mechanism(s) described: many covariates and confounders described; authors explicitly looked for but found no articles examining psychosocial wellbeing; one included paper examined mental health-related outcomes using hospital admissions data • Additional details: data sources include police-reported crime data; authors note lack of longitudinal data
Campbell et al. (2009)	Systematic review of 88 studies on reducing excessive alcohol consumption and alcohol-related harms through policies that address alcohol outlet density • Policies: alcohol availability (privatization of alcohol sales, alcohol bans, and changes in license arrangements) • Outcomes: suicide, interpersonal violence • Mechanism(s) described: distance to alcohol outlets, social aggregation • Additional details: three studies assessed relationships of outlet density with IPV
Fitterer et al. (2015)	Review of 87 studies on effects of alcohol control policies on interpersonal violence • Policies: pricing/taxation, alcohol availability (trading hours, outlet density) • Outcomes: violent offenses/street crime, domestic abuse, child abuse, assaults • Mechanism(s) described: consumption, intoxication • Additional details: Markowitz and Grossman (2000) found relationship between increase in beer taxes and reduction in child abuse rates; authors note lack of crime data linked with information on intoxication levels or consumption location
Fitzgerald et al. (2016)	Evidence synthesis of 63 systematic reviews with a focus on gender differences in alcohol policy impacts • Policies: pricing/taxation, alcohol availability, drink-driving regulation, workplace-based policies, mass media/advertising • Outcomes: sexual assault, rape, child abuse, “violence aimed at wives” • Mechanism(s) described: consumption • Additional details: update of Martineau et al. (2013) review
Gmel et al. (2016)	Systematic review of 160 studies on impacts of alcohol outlet density on alcohol consumption and alcohol-related harms • Policies: alcohol availability • Outcomes: IPV, child maltreatment • Mechanism(s) described: drinking frequency, drinking volume, alcohol sales • Additional details: 10 studies provided data on IPV; 2 studies included child maltreatment; authors describe lack of data to establish causality
Holmes et al. (2014)	Critical review of 138 studies on impacts of alcohol availability on alcohol consumption and alcohol-related harms • Policies: outlet density, hours/days of sale • Outcomes: 38 studies included data on violence generally; 11 studies had measures of IPV; 5 reported on child abuse or maltreatment • Mechanism(s) described: consumption • Additional details: described “acute” outcomes including IPV and emergency department admissions (“other” outcomes included child abuse)
Kearns et al. (2015)	Review of 18 studies on alcohol policies that prevent IPV • Policies: alcohol availability (alcohol outlet density; hours of sale), pricing/taxation • Outcomes: IPV reported police calls, self-report, police-reported DV, IPV-related emergency room visits, intimate partner homicide rates • Mechanism(s) described: substitution effects, changes in drinking • Additional details: could not identify any existing evidence on alcohol advertising/marketing policies and impact on IPV
Kondo et al. (2018)	Review of 28 US studies on neighborhood interventions to reduce violence, including 4 with outcomes related to alcohol • Policies: alcohol availability (including limiting hours of sale), licensing • Outcomes: violence data from police reports, ambulance trips, crime data, hospitalization • Mechanism(s) described: consumption • Additional details: review was not specific to alcohol policy but focused on family violence; studies that included alcohol were related to IPV
Popova et al. (2009)	Systematic review of 59 studies on impacts of outlet density or hours/days of sale on alcohol consumption and alcohol-related harms • Policies: alcohol availability • Outcomes: 15 studies with data on assault or violence; 3 studies with data on child abuse or neglect; 1 study with data on assaults on women • Mechanism(s) described: consumption • Additional details: data sources include police and hospital data
Sanchez-Ramirez and Voaklander (2018)	Systematic review of 26 studies on days/hours of sale • Policy: alcohol availability (days/hours of sale) • Outcomes: 11 studies with data on violence or assault (police records, hospital records); 1 study with data specifically on violence against women • Mechanism(s) described: none • Additional details: data sources include police records, hospital records
Wilson et al. (2014)	Systematic review of 11 studies on alcohol interventions, including alcohol policy, in relation to IPV • Policies: pricing/taxation, alcohol availability (hours of sale, alcohol outlet density), couple-based treatments, individual treatments • Outcomes: self-reported spousal abuse in national surveys, female homicide rates, intimate partner homicide rates, rates of assaults on women, IPV police call-outs • Mechanism(s) described: Consumption; measures of aggression and “psychological aggression” • Additional details: data sources included self-reported spousal abuse, crime data

Evidence of Mechanisms of Policy Action in the Extant Literature

Very few of the reviews discussed possible mechanisms of policy action. If mechanisms were mentioned at all, reviews typically focused on consumption levels as the main mechanism linking alcohol policy to harms. One review (Gmel et al., 2016) noted drinking location and level of social disorganization in the community as potential mediators (or moderators) of policy impacts. There was little discussion of alcohol-related norms, except perceived alcohol availability (Stockings et al., 2018) and perceived approval of youth drinking (Roodbeen et al., 2021).

Most reviews discussed limitations of existing studies and the data used to inform policy. Often authors described the lack of evidence supporting causal inference of impacts of an alcohol policy on harms. For example, Roodbeen et al. (2021) separated studies of secondary societal harm and violence based on whether the “bridging variable” (mediator) of alcohol consumption patterns was also included in each study. Those authors explicitly described a lack of proximal outcomes in the studies they reviewed, and they noted that many papers had been published without the bridging variable, because data linking policy with both consumption and societal harm were difficult to obtain. Further, Siegfried and Parry (2019) commented on a lack of novel methods for analyzing policy impacts and poor attempts to capture the multifaceted nature of alcohol policy; in particular, those authors noted a lack of high-quality evaluations of interventions intended to change drinking environments.

Call for Further Attention to Policy Impacts on Harms to Women and Children

The above summary of evidence suggests a need for methodological and conceptual change if alcohol policies are to reduce harms to people other than the drinker, especially harms to women and children from men’s drinking. Research on alcohol’s harms to others has been increasing; yet only rarely have impacts of alcohol policy on harms to women and children been studied. Our rapid review of reviews, including recent publications, confirms the conclusion from Wilson et al.’s (2014) systematic review of alcohol policy effects on IPV: there is a surprisingly small evidence base of the impact of alcohol policy on violence against women. This suggests that future alcohol policy evaluations should explicitly include analysis of impacts upon women and children (Clifford et al., 2021; Jiang et al., 2019), including community samples of children as well as data on children in the child protection system, to provide essential data to inform future policies (d’Abbs & Togni, 2000).

Changing Alcohol Policy to Reduce Harms to Women and Children

Alcohol policies need to be supplemented by evidence-based and theoretically informed intervention strategies to address the elements preceding and interacting with alcohol consumption that coexist with, and are not sufficiently addressed by, enacting and enforcing strong alcohol control policies. These essential factors include changing the drinking context or environment, modifying drinking norms, and addressing elements of power that specifically relate to harms experienced by women and children. Both health equity and social equity are recognized values in public health (Powers et al., 2006; Rogers, 2006; WHO, 1986) and are affirmed in key documents on global alcohol policy (e.g., WHO, 2010, 2022b). Although there are good reasons to consider cost-effectiveness of policies, measuring policy success only in terms of the highest dollars saved per disability-adjusted life-year (DALY) averted does not necessarily reflect how averted DALYs are distributed among social groups defined by gender (specifically for women, who have less power than men in most societies) and age (notably for children, who have much less power than adults globally). A lack of attention to equity results in lost opportunities to improve health and reduce specific types of harm (Powers et al., 2006).

Taking Harms to Women and Children into Account in Selecting Policy Options

There is relatively little evidence of the impact of key alcohol policies specifically on harms to women and children resulting from men’s alcohol consumption. Therefore, in addition to the need for better evaluation of the effects of these policies on alcohol’s harms to others, it is also important to consider how policies can be made more sensitive to the goal of reducing these specific harms to women (Farrugia et al., 2022) and children. As such, we propose ways to refine these policies to increase their impact. For example, some harms to others, including IPV (Graham et al., 2008), are mainly caused by young men and often are associated with a pattern of heavy episodic drinking common in this age group (Babor et al., 2023). Thus, a pricing/taxation strategy focused on specific beverages consumed by this subgroup may have a greater effect on their drinking, and consequently on the harms they cause. Other innovative policy interventions could include reducing sales of full-strength beer at sporting events, as these drinking contexts have been identified as contributing to violence against women (Forsdike, Hooker, et al., 2022; Forsdike, O’Sullivan, et al., 2022). Another avenue is to use or adapt policies and programs that have demonstrated some evidence of effectiveness. WHO considers some of these approaches (e.g., multi-component community-wide approaches) to be geared specifically toward reducing harm rather than reducing consumption (WHO, 2018). In the following sections, we provide examples of interventions that show evidence of effectiveness and promise for specifically addressing harms to women and children from men’s drinking.

Interventions to Change the Drinking Context

Policies and interventions to modify drinking contexts have the potential to target specific harms. Many existing interventions to change drinking contexts focus on reducing sexual aggression (i.e., sexual assault/rape, unwanted physical contact, harassment) that women experience resulting from men’s alcohol consumption in public drinking contexts. Bystander intervention training programs for staff of licensed premises are increasingly being implemented in various countries. These programs empower and train third parties to intervene verbally or otherwise if they hear threatening dialogue or feel an argument between a couple or other group is moving toward threats or violence. To date, effectiveness of these programs in reducing sexual aggression has not been demonstrated, although one study found improved attitudes and increased willingness to intervene among bar staff who received bystander training (Lopez, 2018; Powers & Leili, 2018). Thus, venue policies for training of bar staff are one way to focus on specific harms to women; if found effective, these could be adopted through state or community policy for general implementation in licensed premises by public health or welfare agencies.

Enhanced policing and enforcement interventions (also typically focused on licensed premises) have shown effectiveness, especially when included with other policies (Babor et al., 2023). Although there has been no evaluation of policing/enforcement applied specifically to harms to women, it is likely that current approaches to reducing sexual violence in drinking venues would benefit from including a policing/enforcement component, especially in high-risk venues and areas with a high concentration of venues frequented by young adults, among whom binge drinking and violence are especially likely (Studer et al., 2015). Of note, equity in policing and enforcement should be at the forefront to enhance effectiveness for all.

Other interventions to prevent harms to women in the drinking environment have focused on individual patrons as they enter or leave licensed premises. Some interventions have been directed toward patrons in queues to enter licensed drinking venues or nighttime entertainment areas. These peer-focused approaches have the goal of reducing alcohol consumption and decreasing victimization of young women by building on peer support and group responsibility. Peer-focused interventions have shown some success in reducing sexual victimization of women (Kelley-Baker et al., 2011), increasing protective actions toward other group members (Byrnes et al., 2019), and reducing some forms of aggression (Brooks et al., 2013). However, they have not yet demonstrated consistent effects on alcohol consumption and other harms, and they have not been broadly implemented or evaluated. Interventions focused on reducing harm among patrons leaving licensed premises have shown some reductions in alcohol-related problems (Moore et al., 2021; Taylor et al., 2020), but again, there is inconsistent evidence of impact, and none of the known programs directed toward exiting patrons have focused specifically on harms to women (or children).

Comprehensive community approaches that combine community leadership, multiple policies and interventions, and enhanced enforcement also have been shown to be effective for addressing specific problems stemming from public alcohol consumption, including violence (Hauritz et al., 1998; Homel et al., 1997) and injuries (Putnam et al., 1993), and youth alcohol consumption at university parties (Ramstedt et al., 2013; Saltz et al., 2009). However, comprehensive community approaches require considerable political will to initiate and implement. To date, no evaluations of community approaches focused specifically on harms to women have been reported in the research literature. A recent longitudinal study showed that local policies limiting alcohol availability reduced child maltreatment cases in Australia, suggesting that community interventions, particularly when introduced with local organizations, may be promising (Laslett et al., 2018).

Overall, policies and interventions to change drinking contexts offer feasible options for reducing harms to women in public settings, including licensed venues, although evidence for effectiveness is generally weaker. Most of these options require costs to implement (although some costs could be passed on to licensed venues or alcohol consumers themselves), as well as staff who are willing and empowered to support these interventions. In private settings, including private homes, community approaches could combine enhanced enforcement and treatment for people with alcohol problems with other interventions to target reduction of alcohol-related violence.

Policy Interventions to Reach Specific Individuals

In addition to policies directed toward environments in which alcohol consumption occurs, another avenue for intervention focuses on particular individuals. Although some individual-focused restrictions with past evidence of effectiveness (such as alcohol rationing) may be seen by some as interfering too much with the market and individual consumer choices, there are some individual-focused policies, such as license suspension for persons convicted of driving under the influence of alcohol (drink-driving), that are already commonplace and effective (Babor et al., 2023). There is some evidence that certain measures—specifically those adopted and implemented to deter alcohol consumption by persons who have committed an alcohol-related offense unrelated to IPV—can substantially reduce harms to women. The 24/7 Sobriety program in the U.S. state of South Dakota included a ban on alcohol consumption for persons convicted of drink-driving, as well as “swift, certain and modest sanctions” (up to 2 days in jail) for participants who failed the twice-daily breath alcohol testing. Evaluation of this program showed that IPV arrests dropped by 9% in the implementing counties (Kilmer et al., 2013), demonstrating that an individually applied ban on alcohol consumption, enforced through the legal system, can reduce rates of IPV.

Over the last century, many countries instituted systems to ban specific individuals from purchasing or consuming alcohol when the person is inclined to violence or inflicting other harms after alcohol consumption. These individual-focused interventions may impact drinking in private venues such as homes. For instance, for many years in Ontario, Canada, individuals could apply to have another person banned from purchasing alcohol at government alcohol stores; women were more likely than men to take advantage of this policy protection (Thompson & Genosko, 2009). In Australia’s Northern Territory, a “banned drinker” system was implemented, and a study is underway examining its effects on IPV and other outcomes, as evidenced in case reports by police, child protection agencies, and government-run safe houses for women and children (Miller et al., 2022).

Another approach to reducing harms from alcohol consumption is to declare “dry zones” where no alcohol consumption is allowed. Most commonly, these are public places such as parks and roads (Manton et al., 2014). Such measures may have a positive impact on “amenity” in public spaces (i.e., reducing alcohol-related harms and nuisances caused by neighbors or strangers), but could result in negative impacts on home life if the effect is to move alcohol consumption into private spaces. In Australia’s Northern Territory and Western Australia, particularly in areas where many Aboriginal Australians reside, dry zones are common, and it is also possible to declare a particular home legally “dry.” Qualitative studies are equivocal on the question of whether such restrictions have improved women’s safety (e.g., Brown, 2014; Goldflam, 2010), but introduction of local dry zones in Western Australia was associated with decreases in substantiated child abuse and neglect cases (Laslett et al., 2022). Nine U.S. states have some dry counties and another 13 have dry municipalities (including cities, towns, and lands of some Indigenous communities) where alcohol sales are not permitted; additional localities restrict certain types of alcohol sales, such as liquor by the drink (NABCA, 2017). An early cross-sectional study comparing “wet” and “dry” counties in Arkansas (Fullington et al., 1985) found that, while violent and property crimes and drink-driving arrests were significantly more likely to occur in “wet” counties, there was no significant difference in offenses against family and children. These examples suggest that some communities are open to rather broad measures for addressing alcohol consumption and norms about where drinking is and is not permitted.

Another individual-focused strategy is general alcohol rationing. In the early 20th century, Sweden implemented a rationing program that limited a household’s monthly purchases of spirits, the main alcoholic drink. When the system was abolished in 1955, there was a 25% increase in total alcohol consumption over the next year (Mäkelä et al., 2002), with increases especially concentrated among heavier drinkers (Norström, 1987). Drinking-related criminal offenses also roughly doubled at the end of rationing in Sweden (Mäkelä, 2002; Mäkelä et al., 2002). Another example of alcohol rationing was implemented in Greenland in 1979; calls to police concerning domestic quarrels in Nuuk, the capital, fell by 78% compared to an equivalent period in the previous year. Greenland’s rationing system was abolished in 1982, following which public children’s shelters were soon overflowing, and police calls for domestic quarrels in Nuuk were estimated to have doubled (Room et al., 2003; Schechter, 1986). It remains to be determined whether alcohol rationing may be an acceptable approach for controlling alcohol consumption in the current era, but evidence suggests it may be broadly impactful if adopted and may be a policy option for certain communities.

Access to Specialized Treatment

Greater attention also must be paid to treatment as an avenue for reducing harms to women and children resulting from men’s alcohol use. Alcohol intoxication and alcohol use disorder (AUD) are consistent and strong risk factors for IPV perpetration (e.g., Cafferky et al., 2018; Yu et al., 2019). There is some evidence that individual treatment to reduce alcohol consumption and to treat AUD can also reduce alcohol-related IPV perpetration (Murphy & Ting, 2010), although much of the research to date has methodological limitations, and relatively few studies have examined combined treatment for alcohol use and IPV (Wilson et al., 2014). Specialized treatment strategies may offer one avenue for preventing harms to women and children.

Reviews have found that behavioral couples therapy and alcohol-focused behavioral couples therapy—two specialized approaches that treat the dyad rather than just the person with AUD—are successful in reducing frequency and consequences of alcohol use and improving relationship satisfaction (Mutschler et al., 2022; Powers et al., 2008). Couples therapy for IPV remains controversial, and is considered unsafe due to the potential of increased abuse toward victims and retaliation after a session (Hurless & Cottone, 2018; Stith & McCollum, 2011). However, a meta-analysis reported that couples therapy had a moderate effect in reducing perpetrated situational relationship IPV by men toward their female partners (Karakurt et al., 2016). While the review only included six studies, Karakurt et al. (2016) conclude, “there is certainly reason to re-evaluate the role of couple therapy in IPV treatment and cautiously increase its application” (p. 578). However, without appropriate training, psychologists, family therapists, and mental health and substance use treatment program staff lack knowledge about how best to respond to IPV, and may offer ineffective—or even dangerous—advice (e.g., suggesting the victim leave the perpetrator), putting victims at greater risk (Dudley et al., 2008; Karakurt et al., 2013; Radcliffe & Gilchrist, 2016).

Male IPV perpetrators in AUD treatment typically do not meet inclusion criteria for IPV perpetrator programs, and men in AUD treatment are rarely referred to supplemental IPV perpetrator programs (Klostermann & Fals-Stewart, 2006; Timko et al., 2012); so, some specialized treatment interventions focus explicitly on perpetrators of IPV. Stephens-Lewis et al. (2021) conducted a meta-analysis of four trials for male IPV perpetrators with substance use problems, comparing integrated perpetrator interventions vs. substance use treatment only. They found significant differences in physical IPV perpetration at the end of treatment for the integrated interventions compared to substance use treatment as usual, but there were no statistically significant differences in outcomes at the end of the longer-term follow-up period. Regarding harm to children, specialized interventions that focus on improving parenting practices and family functioning may be effective in reducing problems experienced by children affected by parental substance abuse (Calhoun et al., 2015), and pooled data from 16 studies showed participation in family treatment drug courts was associated with family reunification (Zhang et al., 2019).

While AUD treatment and specialized interventions for male IPV perpetrators with AUD are promising for reducing harm to others, access to such programs is often stigmatized and availability is limited. WHO surveys suggests that among people with alcohol or drug use disorders, only 7% had received at least minimally adequate treatment for substance misuse in the past year (10%, 4%, and 1% in high-, upper-middle-, and lower-middle-/low-income countries, respectively) (Degenhardt et al., 2017). Thus, reliance on specialty alcohol treatment, at least as currently implemented, likely would be insufficient for reducing harms to women and children resulting from men’s alcohol consumption.

Conceptual Model to Improve Policy Impacts

We present a conceptual model (Figure 1) depicting pathways from and interactions with recommended alcohol policies to spur consideration of diverse means to improve policy impacts and reduce harms to women and children resulting from men’s alcohol use. In addition to policy and intervention effects on men’s drinking and intoxication, we include characteristics of drinking contexts; drinking norms and beliefs about intoxication; and social norms about masculinity, power, and sexuality as plausible mechanisms linking alcohol policies and other interventions with harms from others’ drinking (Becker & Tinkler, 2015; Graham & Homel, 2008). For example, in our model, advertising bans and restrictions are considered a potential policy lever for addressing attitudes and norms about masculinity, power, and sexuality, particularly through restricting the pairing of alcohol with sexually suggestive images.

Figure 1. Conceptual model linking alcohol policies to harms to women and children.

Broad inequalities in power and social norms around masculinity, male sexuality, and male dominance can be particularly toxic in combination with alcohol consumption and intoxication; as such, resulting harms to women and children are unequally distributed across countries and population subgroups (Laslett, Graham, et al., 2021). However, there is a marked lack of data on who is affected by whose drinking and how harms to women and children relate precisely to contextual determinants and moderators (including household-level factors); those data could aid understanding of these mechanisms and how they might be changed (WHO, 2022a). Despite a lack of extant data, there are multiple additional factors that we posit as household-level moderators of the associations depicted between alcohol policies, mediators, and harms. In Figure 1, these are depicted across the top, with dashed arrows to indicate interaction with (effect modification of) the lines below. Three important household moderators are gender roles, socioeconomic status (SES), and household composition. For example, relationships between alcohol pricing, men’s alcohol consumption, and financial harms to women may be stronger in lower-SES households; however, this remains to be empirically tested. This is not an exhaustive list of moderators, and there may be many other household factors that impact the associations of interest. These household determinants could also be directly targeted for intervention to reduce harms to women and children.

Drinking norms also affect alcohol consumption and harms. Alcohol use in many low- and middle-income societies is characterized by high levels of abstinence on the one hand, and heavy episodic alcohol consumption on the other (Babor et al., 2023; WHO, 2018). In these societies, even with high rates of abstention from alcohol, aggression, misconduct, and violence caused by others’ alcohol consumption result in harms to women and children. For example, in the Asia-Pacific region, where just 33% of the population aged 15 or older drinks alcohol but 41% of those who do are heavy drinkers, women reported being threatened by drinkers in public places (Waleewong et al., 2018), and men who drank heavily were significantly more likely to report perpetrating IPV than those who did not drink (Laslett, Graham, et al., 2021; Ramsoomar et al., 2021).

Contextual Moderators Relevant to Understanding Variations in Policy Impacts

In addition to the household-level moderators, the model highlights the importance of contextual variables (on the far left). These are likely to be independent determinants of harms to women and children resulting from men’s alcohol consumption that could be directly targeted for intervention to reduce harms to women and children. A U.S. analysis found that state-level socioeconomic status was associated with fewer family and financial harms due to someone else’s alcohol consumption (Cook et al., 2021), and another found that, for people under age 40, stronger state alcohol control policies were associated with fewer aggressive harms caused by a person who had been drinking alcohol (Greenfield et al., 2019). Contextual variables also may moderate any of the associations of interest. For example, associations between advertising bans on social norms about masculinity, power, and sexuality are likely to vary by a community’s religious culture. WHO acknowledges the importance of cultural context when implementing cost-effective alcohol policy interventions (WHO, 2010), as well as challenges local conditions may create (WHO, 2022b).

Another broad contextual variable is gender equality. Greater gender equality is associated with lower alcohol consumption among men (King et al., 2020; Rahav et al., 2006; Roberts, 2012). Research has examined the relationship between gender equality and violence against women generally (e.g., Roberts, 2011), but less is known about relationships between gender equality and alcohol-related harms. Increased gender equality could provide women with more of their own economic resources and educational and employment opportunities. Thus, women in more equitable societies might not be as dependent upon—and thus forced to stay with—partners who cause alcohol-related familial or financial harms. Equality also may affect norms about drinking and masculinity. One U.S. study found that state-level drinking culture was more strongly associated with harms to women from others’ drinking in states with low gender equality than in states with high gender equality (Karriker-Jaffe et al., 2019).

Country-level economic development also impacts alcohol policy implementation and enforcement. The African continent has historically been characterized as a region with weak alcohol policies, resulting in many African countries being targeted for market expansion by a vociferous and relentless alcohol industry (Morojele et al., 2021; Van Beemen, 2019). While some African countries have implemented alcohol taxes (e.g., South Africa and Botswana), implementation of many other cost-effective alcohol policies remains a challenge. Specifically, there is quite low population coverage for advertising restrictions in African countries, and physical availability restrictions also have proven difficult to implement and enforce. Where cost-effective policies have been adopted, contextual factors often impede meaningful and effective implementation. For example, in South Africa, national legislation, provincial laws, and local bylaws are not applied in a harmonized manner across the country, leading to uneven alcohol regulation (Ferreira-Borges et al., 2017). Furthermore, interference from the alcohol industry threatens to reverse alcohol policy gains in some countries (e.g., alcohol taxation in Botswana; Pitso & Obot, 2011).

Suggested Ways Forward

Our rapid review identified a lack of research on the effects of alcohol policies on harms to women and children. When policy research does include alcohol’s harms to others, the emphasis is often on violence or assault generally, without information on who is perpetrating or suffering the violence, despite recognition that this information is relevant to understanding causal mechanisms and possible means of intervention. Thus, significant questions remain about the potential of recommended alcohol policies to decrease harms to women and children from men’s drinking. For example, can policy interventions change the masculinized drinking contexts and social norms that facilitate men’s drinking to excess? Can these policies be coupled with other interventions to reduce both alcohol consumption and harms? How do local contexts impact policy effects on harms from men’s alcohol use? By including harms to women and children as key outcomes of alcohol policy evaluations, we will gain essential data to answer these questions and to inform future interventions to reduce the burden of men’s alcohol consumption.

This review centers on policies focused on alcohol and drinking contexts and does not go in depth on factors such as gender inequality and poverty that contribute to harms to women and children and also moderate the impacts of alcohol. Recent research has demonstrated how both policymakers (Farrugia et al., 2022) and researchers (Moore et al., 2022) tend to focus exclusively on the alcohol (pricing, availability, how it is served, etc.) and on applying policies to all drinkers, despite evidence that many harms to others are caused by a small and identifiable subgroup of drinkers (e.g., violence toward both women and men is mostly perpetrated by young men). Additional research is needed to develop and evaluate policies that might reduce harms to women and children from men’s drinking without specifically focusing on the alcohol (e.g., policies that decrease poverty and women’s dependence on men’s incomes, or programs to teach bystander intervention to college students in order to prevent sexual assault).

As noted above, women’s movements in the late 19th and early 20th centuries were strongly intertwined with temperance movements of that era (Schrad, 2021), and a primary narrative portrayed the adverse effects of a man’s alcohol consumption on his wife and children. There are current examples of women’s movements, particularly in low- and middle-income polities, defining men’s alcohol consumption as a major problem for women and agitating for local reduction or prohibition of alcohol availability, for instance in Aboriginal Australian settlements (Brady, 2019), on Pacific islands (Marshall & Marshall, 1990), and in states in India (Larsson, 2006).

In other societies, alcohol has become the “elephant in the room” in discussions on policy interventions to prevent and reduce violence against women (Braaf, 2012), as there is concern for many involved in such discussions that a focus on alcohol will undermine the recognition of gender inequality as the root cause of violence against women (Our Watch et al., 2015; Webster et al., 2018). As such, current policy frameworks to prevent violence against women operate on the principle that it is not alcohol consumption itself that increases violence against women, but rather it is the interaction of alcohol consumption with social norms related to gender. Alcohol consumption is thus viewed as a reinforcing factor weakening prosocial behavior toward women (Our Watch et al., 2015). On the other hand, in a review of more than 30 years of research, Leonard and Quigley (2017) argue that “excessive alcohol use does contribute to the occurrence of partner violence and that contribution is approximately equal to other contributing causes such as gender roles, anger and marital functioning” (p. 7). Radcliffe et al. (2021) reported that “while the psychopharmacological effects of substance use (including intoxication, craving, and withdrawal) featured in participants’ accounts of IPV, it was rarely the only explanation” (p. 10304). Thus, there is scope for better understanding the pathways of alcohol intoxication, craving, and withdrawal leading to violence against women and children while also recognizing broader contextual and social factors, including gender equality and economic independence for women. Harms to women and children resulting from men’s alcohol use, including IPV and other issues, should be routinely included as outcome measures in alcohol policy evaluations (Wilson et al., 2023). As Graham et al. (2011) argue:

Ignoring the presence of alcohol will neither eliminate its role in intimate partner violence nor prevent its being used as an excuse for violence. On the contrary, the more we know about how alcohol affects violence, including intimate partner violence, the better able we will be to develop effective prevention strategies and treatment responses. (p. 1516)

To date, cost-effective alcohol policies such as pricing strategies and availability restrictions have largely not considered the implications for women and children. With more focused attention, these key alcohol policies can be paired with other evidence-based or otherwise promising interventions to reduce alcohol-related harms suffered by women and children, including IPV, child abuse, and other psychological, financial, and social harms resulting from men’s drinking.

Highlights:

• Men’s alcohol consumption can have secondary health effects on women and children.

• Alcohol policies are effective tools to addressing alcohol-related harms, but have not been properly developed or considered in the context of violence against women and children.

• Outcomes and mechanisms of change are limited within existing alcohol policy research to primarily focus on individual impacts and consumption.

• A new conceptualization of alcohol policy that addresses harms to women and children could include a focus on changes to the drinking context, comprehensive (multi-pronged) community and policy interventions, and individual-focused strategies.

• We need better research to understand how current alcohol policy does (or does not) impact harms to women and children and to reframe how alcohol policy can be improved to address violence and broader public health impacts.