Youth understanding of substance use and pregnancy

With marketing of alcohol and nicotine delivery products to youth, legalization of cannabis, and the crisis in prescription pain medication use, there are new opportunities to have conversations with youth about substance use and pregnancy, with the aim of reducing the harms and improving their overall health.

What do we know about youth understanding of substance use and pregnancy?

Existing research and data on youth behaviour provide a window.

One U.S. study showed a relationship between pregnancy and prior substance use among adolescents, and among younger adolescents in particular.

  • 59% of pregnant teens and 35% of nonpregnant teens reported having used substances in the previous 12 months.
  • Some substance use continued in pregnancy particularly among younger pregnant adolescents ages 12-14. (1)

The McCreary Centre Society conducts an adolescent health survey in BC every 5 years. The 2018 evaluation is underway, but findings from 2013 indicated a number of factors related to youth substance use and pregnancy.

Those at higher risk for harmful alcohol use include:

  • Youth in rural areas
  • Youth who were born in Canada
  • Youth who were employed
  • Youth living in poverty
  • Youth experiencing abuse or violence
  • Sexual minority youth
  • Peer relationships have risks in terms of starting drinking earlier and binge drinking particularly when friend groups are large.

Those at greater risk of being involved in a pregnancy include:

  • Youth who first had sex before their 14th birthday
  • Youth in rural areas
  • Youth who had been in government care. Among these youth, girls were more likely than boys to be have been involved in a pregnancy
  • Youth who had been physically abused
  • Youth who had been sexually abused. Among these youth, males who were more likely to have been involved in a pregnancy.

The Ontario Student Drug Use and Health Survey (OSDUHS) from 2017 shows that:

  • 17% of youth have participated in binge drinking and 16% cannot remember what happened during that time
  • Boys are more likely to use e-cigarettes and all forms of tobacco, over-the-counter cold/cough medications, energy drinks, cannabis, and psychedelics
  • Girls are more likely to use prescription opioids for pain relief and tranquilizers medically

IMPART info sheet on “Youth, Gender and Substance Use” recaps how the harms of early substance use are gender-specific.

How do we approach building awareness and prevention?

Opening “Doorways to Conversation” about substance use and pregnancy allows for brief interventions and support for youth as well as women and girls. Many providers think that they need to have appropriately tested screening tools along with the knowledge, skills and confidence to conduct them. As one United Nations study found, less than 30% of health providers routinely screened youth for substance use for these reasons.(2)

Trauma-informed, culturally relevant, and gender-specific relational approaches build trusting relationships that can support youth who may be dealing with more complex issues like violence and abuse, gender identity, or the foster care system.

Promising Approaches for Reaching Youth on Substance Use and Pregnancy

Here are some current promising approaches to improving youth understanding of substance use and pregnancy in Canada.

Projects like “Let’s Get Real About Drinking Alcohol” are trainings for youth focusing on the interconnection of substance use, safe sex, birth control, and drinking during pregnancy. You can view a webcast about the project here.
This handout offers conversation starters on substance use for group facilitators. Girls Action Foundation “Take Care” program provides a curriculum and resources for facilitators of girls’ groups to promote critical thinking about healthy living including substance use and sexuality.
Canadian Centre on Substance Use and Addiction (CCSA) has created a low-risk drinking guide for youth.

Online sexual health resources for youth:

Teen Health Source Native Youth Sexual Health Network

  1. Christopher P. Salas-Wright, Michael G. Vaughn, Jenny Ugalde, Jelena Todic. Substance Use and Teen Pregnancy in the United States: Evidence from the NSDUH 2002–2012. Addictive Behaviors, 2015; DOI: 10.1016/j.addbeh.2015.01.039
  2. Chakravarthy, B., Shah, S., & Lotfipour, S. (2013). Adolescent drug abuse – Awareness & prevention. The Indian Journal of Medical Research, 137(6), 1021–1023.

Coercive messaging for pregnant women?

In 2016, the UK Chief Medical Officer with endorsement from the Royal College of Midwives updated advice on drinking alcohol during pregnancy, stating:

“I want pregnant women to be very clear that they should avoid alcohol as a precaution. Although the risk of harm to the baby is low if they have drunk small amounts of alcohol before becoming aware of the pregnancy, there is no ‘safe’ level of alcohol to drink when you are pregnant.”

This month, the Centre for Pregnancy Culture Studies (CPCS) and others have been getting a lot of press for the claim that women are being unnecessarily frightened by this most recent advice and may be terminating pregnancies because of it (see post below for facts on this). They say that women who choose to drink at low levels during pregnancy are being stigmatized when the facts don’t support the guidelines.  Further, they claim “the exclusion of women from an ordinary activity on the basis of ‘precaution’ can more properly be called sexist than benign.” (The Guardian, May 17, 2017)

That they see alcohol as a normal activity that women should have a right to, does a disservice to both feminism and to alcohol education. There is definitely here a reluctance to examine alcohol as a substance that has the potential to negatively affect health in all situations, and is a teratogen in the context of pregnancy.  More, rather than less, discussion of alcohol on men’s and women’s health, and not only in relation to preconception and pregnancy would be welcome.  Canada’s Low Risk Drinking Guidelines could inspire more public consideration of what we know and don’t know about alcohol.

CPCS’s comments were in tandem with a larger Policing Pregnancy conference held last week. And on points of pregnancy policing, we agree. Facts show that policing pregnancy increases stigma and pushes women to the margins so that they don’t get the help they want [1]. Women should not be policed for their actions in pregnancy, rather they should have access to information and conversations that can support their decisions.

Preconception and prenatal health care with a caring and knowledgeable health care provider is critical to helping women have the best health and pregnancy possible. How many women have the kind of discussion of alcohol and the care they deserve?

As one opinion writer noted in response to the coverage, the tinkering with alcohol guidelines for pregnant women is not the harm here – it is the lack of services and care that pregnant women receive.


For more information, see these earlier posts:

Policing or Supportive? Why We Should Test Pregnant Women for Alcohol Use, July 7, 2015

Do Concerns about Alcohol Use during Pregnancy Lead Women to Consider having an Abortion? February 1, 2013


  1. Poole, N. and B. Isaac, Apprehensions: Barriers to Treatment for Substance-Using Mothers. 2001, British Columbia Centre of Excellence for Women’s Health: Vancouver, BC.


Heavy drinking among women: Normalising, moralising and the facts

why-do-girls-and-women-drinkThe Washington Post recently featured an article on the normalisation of heavy drinking for women. Citing targeted advertising and multiple media, particularly to girls on social media, the article outlines the dangers in this trend of treating alcohol as a lifestyle rather than a drug. The obvious dangers are that normalising heavy drinking will increase the number of alcohol-exposed pregnancies and have a negative impact on girls’ and women’s health. Advertising exploits the positive connections women seek with each other, making it about drinking together and promoting it on t-shirts, cups, cards and even wine labels.

The liquor industry is attempting to link drinking with gender equality. But there is nothing equal or liberating about the risks women and girls face, or the distain that is heaped upon them for drunkenness. A recent article in the Daily Mail supported public shaming of binge drinking by young women in particular, and featured numerous denigrating photos of them on New Year’s Eve. Many pointed out the hypocrisy of moralising (Suzanne Moore, The Guardian). A different dialogue is needed: one that focuses on facts, health, education, and creates platforms of conversation and support.

It’s science not sexism that reveals the risks and consequences of heavy drinking for women and girls, and ways to reduce harm. We have learned why women may drink, the effectiveness of non-judgmental approaches to reducing harm, and best practices and policies for promoting health. The facts are not as confusing as some suggest and by focusing on them, we can counter normalising and moralising.

  • Women’s bodies process alcohol differently, so woman’s alcohol level will be higher than a man drinking the same amount. Canada’s low-risk drinking guidelines reflect this sex difference.girls-alcohol-pregnancy-picture
  • Men, in general, are riskier drinkers than women as evidenced by rates of alcohol-related injury and mortality, but women have more chronic health risks related to heavy drinking (Wilsnack & Wilsnack, 2013).
  • Beyond the risk of addiction, Jennie Cook’s research found a causal link between drinking and at least 7 forms of cancer for both sexes (Connor, 2017).
  • Claims of protective factors for cardiovascular disease are coming under scrutiny and skepticism even as these claims remain a core industry research topic and argument for drinking (Chikritzhs, Fillmore, & Stockwell, 2009)
  • How and when we present the facts of drinking alcohol to women and their partners makes a difference to the health of women and their families (See 10 Fundamental components of FASD Prevention from a women’s health determinant perspective).
  • Prevention of alcohol harms requires a tiered response in policy, practice, and messaging (See FASD Prevention: Canadian Perspectives)
  • Comprehensive and integrated programs that build relationships work best for supporting women in making healthy choices for themselves and their families (See Mothercraft’s Mother-Child Study)


Chikritzhs, T., Fillmore, K., & Stockwell, T. I. M. (2009). A healthy dose of scepticism: Four good reasons to think again about protective effects of alcohol on coronary heart disease. Drug and Alcohol Review, 28(4), 441-444. doi:10.1111/j.1465-3362.2009.00052.x

Coalescing on Women and Substance Use.

Connor, J. (2017). Alcohol consumption as a cause of cancer. Addiction, 112(2), 222-228. doi:10.1111/add.13477

Wilsnack, R. W., & Wilsnack, S. C. (2013). Gender and alcohol: consumption and consequences. In P. B. Peter Boyle, Albert B. Lowenfels, Harry Burns, Otis Brawley, Witold Zatonski, Jürgen Rehm (Ed.), Alcohol: Science, policy and public health (pp. 153-160). Oxford, England: Oxford University Press.



“Alcohol and Women” resource from Éduc’alcool (Quebec)

- 'Version anglaise - EA-Alcohol-and-Women_pdf'

A few years ago, the Quebec-based non-profit organization, Éduc’alcool, ran a wonderful campaign promoting Canada’s new sex-specific low risk drinking guidelines.

Éduc’alcool has just released a new publication called “Alcohol and Women.” The 16-page resource (available in French and English) discusses: How do women drink? Why do they drink? What impact does drinking have on their health and well-being?

The resource is intended for women of all ages as well as men.



Statistics on women and alcohol in Quebec indicate that:

  • 82% of Quebec women drank alcohol in the last year; two thirds of those women drink regularly.
  • 13% of women who drink do so four or more times a week.
  • Among women 18 to 24, the annual prevalence of excessive drinking is 83%; among women 25 to 34, it is 70%, and among women 45 to 54, it is 53%.
  • Among teenage girls 15 to 17, 5% drink excessively at least once a month, and among young women 18 to 24, 19% do.
  • 0.9% of women in Quebec have been diagnosed as alcohol dependent.

“Alcohol and Women” is available for download from the Éduc’alcool website. Free copies can be ordered from Éduc’alcool at 1-888-ALCOOL1. As well, the publication will soon be available in hospitals, CLSCs (local community service centres) and Société des alcools du Québec outlets.


A ReThink of the Way We Drink – “Whiteboard Med School” video from Dr. Mike Evans

Some of you might be familiar with Dr Mike Evans and the great work of the Evans Health Lab. The Evans Health Lab “fuses clinicians and creatives, filmmakers and patients, social entrepreneurs and best evidence to create “edutaining” healthcare information.”

In 2011, his YouTube video  “23 and 1/2 Hours: What is the single best thing we can do for our health?” went viral. To date, the video has been viewed 7.5 million times and translated into eight languages, including Arabic and Gaelic.

The latest video in his “Whiteboard Med School” series is called “A ReThink of the Way We Drink.” In this video, he explores some of the recent research on alcohol and health. He touches on low risk drinking guidelines and sex-specific differences. He also talks about why many health care providers are often reluctant to ask about alcohol use due to fears about alienating patients or appearing judgmental.

Check out this video and others here.


Cancer and Alcohol: Canada’s Low Risk Drinking Guidelines


Last week, the Canadian Centre on Substance Abuse (CCSA) released Cancer and Alcohol, the first in a series of summaries of topics covered in Canada’s Low-Risk Alcohol Drinking Guidelines. These summaries were created to address specific health concerns or to discuss how to apply the low risk drinking guidelines for certain populations.

The CCSA will release the next summary topic, Youth and Alcohol, on Friday, January 31, 2014, which will address why youth up to the age of 25 should minimize their alcohol consumption. The following Friday, February 7, they will release a Women and Alcohol summary that will address the unique effects of alcohol on females and why the low-risk drinking limits differ for women and men.

The Cancer and Alcohol summary was developed on behalf of the National Alcohol Strategy Advisory Committee (NASAC) in collaboration with the Canadian Cancer Society. It highlights how drinking an average of one drink a day can increase the risk of developing certain types of cancers.

While the Low Risk Drinking Guidelines overall suggest that women consume no more than 10 drinks a week and no more than two drinks a day most days in order to reduce long-term risks for multiple chronic illnesses, women who are interested in reducing their risk of developing cancer should drink less than one drink a day.

That said, even small amounts of alcohol increase the risk of certain cancers, so the less alcohol you drink, the more you reduce the risk of developing cancer. Any type of alcohol — beer, wine or spirits — increases the risk of cancer.

standard drink

All the summaries are available from the CCSA website at this location: The guidelines and summaries are available in French.

For more on Canada’s Low Risk Drinking Guidelines, see previous posts:

Rethink Your Drinking campaign from southwestern Ontario


Rethink Your Drinking is an awareness campaign from nine health units in southwestern Ontario.

Based on Canada’s Low Risk Drinking Guidelines, the campaign does not encourage individuals to stop drinking but rather to rethink their drinking and find a healthier relationship with alcohol.

The website includes downloadable posters and fact sheets on different aspects of the guidelines. “Size Matters” helps individuals to understand what is a standard drink. “Time Matters” describes the importance of spacing drinks and drinking slowly. “Choice Matters” describes impairment, injury and alcohol myths. “Sex Matters” looks at sex-specific differences in the guidelines and why women are more vulnerable to the effects of alcohol. “Everything Matters” examines the long-term risk of alcohol use including stroke, cancer and other chronic disease.

The Rethink Your Drinking website has a section specific to women. (The Low Risk Drinking Guidelines have different suggested limits for women and men and suggest avoiding alcohol altogether when pregnant, planning a pregnancy, or about to breastfeed).

For more on Canada’s Low Risk Drinking Guidelines, see previous posts:

Girls, Women and Alcohol: Making Informed Choices resource from Healthy Child Manitoba

FASD prevention resource from the Government of Manitoba

Pages from alcohol_women

Healthy Child Manitoba has developed a resource called Girls, Women and Alcohol: Making Informed Choices which is designed to help women make healthy and well-informed choices about their alcohol use. The resource was written and reviewed by women for women to provide useful information about alcohol.

The resource is 16 pages and has six sections:

  1. Low Risk Drinking
  2. Risks of Heavy Drinking
  3. Individual Responses to Alcohol
  4. Other Factors
  5. Support for People Close to You
  6. Resources

The resource states: “There is no known safe amount of alcohol, at any stage of pregnancy, that will completely prevent the risk of having a child with FASD.”  (p. 10)

This is a great resource as it’s not focused solely on health risks of alcohol or intended to stop women from drinking alcohol. Instead, it focuses on factors and issues that women might consider in making healthy decisions for themselves.

Pages from alcohol_women-2Pages from alcohol_women-3

Alcohol Screening, Brief Intervention and Referral: Helping Patients Reduce Alcohol-related Risks and Harms resource

SBIR - Home

Alcohol Screening, Brief Intervention and Referral: Helping Patients Reduce Alcohol-related Risks and Harms is a resource for Canadian family physicians, nurse practitioners and other healthcare professionals developed by the College of Family Physicians of Canada and the Canadian Centre on Substance Abuse.

The online resource, available in both English and French, uses a three-step alcohol screening, brief intervention, and referral process. The resource section includes information on seven sub-populations, including women, alcohol and pregnancy, and alcohol and breastfeeding.

Research evidence supports screening and brief interventions for alcohol misuse as efficacious and cost-effective in a variety of settings.

There are a range of screening tools out there (see posts listed below for more); this resource incorporates Canada’s Low-Risk Alcohol Drinking Guidelines which were released in November 2011.

SBIR Clinical Guide

For more on screening in primary care settings, see previous posts:

Danish campaign suggests that everyone “Stick a Cork in it” on October 11th

Check out this article “Annual fall anti-drinking campaign underway” (October 3, 2012) in The Copenhagen Post on a low risk drinking campaign in Denmark.

The Danish national health board, Sundhedsstyrelsen, has been running an annual fall campaign with print, TV and billboard ads to promote moderate drinking.

Sundhedsstyrelsen suggests that women should drink no more than 7 drinks per week and that men should drink no more than 14 drinks a week.

This year, the campaign has a focus on the link between cancer and alcohol, including detailed information on breast cancer.

In terms of alcohol use during pregnancy, the campaign website recommends that women who are pregnant or trying to conceive avoid alcohol. “There is no lower limit for maternal consumption of alcohol during which it is safe to say that alcohol consumption will be harmless to the fetus.”

As a way of supporting the campaign, Sundhedsstyrelsen is asking that everyone  ‘Stick a Cork in it” on Thursday, October 11th and completely abstain from drinking.

Check out this article on the 2009 campaign which focused on youth ages 16-25. You can also take a look at the World Health Organization’s alcohol and health profile on Denmark here.

For more on low-risk drinking/moderation campaigns in other countries, see previous posts: