We interviewed 20 WWH with a history of hazardous drinking patterns who completed a randomized clinical trial to reduce or quit their drinking. Among participants, the mean age was 49.3 (Standard Deviation [SD] = 6.9), 85% were Black women, 60% had less than a high school education, 60% were single, and 95% were unemployed. At the 7-month follow-up of the parent study, most women reported either a reduction in drinking (30%) or complete cessation of drinking (55%). Table 2 provides a detailed summary of participant demographics.
The qualitative analysis revealed three overarching domains characterizing the lifetime drinking trajectories of WWH. These domains include: (1) Onset of Alcohol Use, encompassing early alcohol exposure, the influence of parental drinking during adolescence, and the role of peer dynamics in shaping risk behaviors; (2) Escalation to Hazardous Drinking, which captures patterns of increasing alcohol consumption, shifts in drinking behavior, the use of alcohol as a coping mechanism, and the co-use of alcohol and other substances; and (3) Post-Study Drinking Continuation, which reflects ongoing alcohol use following the conclusion of the parent study, including alcohol’s perceived impact on mental health, its social functions, perceived health benefits, and factors contributing to successful reductions in drinking. Table 3 presents the thematic codes and their definitions. A detailed discussion of each domain and its prominent codes is provided below.
Drinking onset
When WWH talked about the circumstances surrounding the onset of their drinking, several themes emerged:
Early alcohol exposure
Many participants began the story of their drinking onset by recounting early exposures to alcohol during childhood or adolescence. These early encounters, occurring in both supervised and unsupervised settings, appeared to normalize alcohol consumption and contributed to earlier patterns of escalation. Most participants reported exposure to alcohol before the age of 18, with some recalling initial experiences as young as 10 years old. Notably, some participants differentiated between their first taste of alcohol and the onset of regular drinking, highlighting a developmental progression from experimentation to habitual use.
“My first beer I had when I was 11 years old. I remember it was a Miller Lite. It was the little bottle, it was this big. They used to sell them here [name of state]. That was my first beer. But then I started drinking when I was 16.” (Age 45, Hispanic/Latino, Quit drinking).
“Fourteen… Oh no, about 10 to 14–14 is when I really started escalating. From 10 to 14 I was just stealing drinks here and there. When my mom would leave an empty drink and I would go drink it, stuff like that.” (Age 50, non-Hispanic White, Quit drinking).
The effect of parental drinking on adolescents
Many participants highlighted the influential role of family in shaping their early alcohol use. Several described familial behaviors that normalized or facilitated drinking, such as collective family drinking or parents consuming alcohol openly in front of their children. In numerous accounts, participants recalled their parents not only modeling alcohol use but also actively encouraging them to drink, sometimes beginning in childhood or early adolescence. These experiences contributed to the perception that alcohol consumption was acceptable or even expected within the family environment.
“My dad taught us that stuff. It was like an Italian family where you drink wine at the dinner table. That’s what we did. We drank wine. Sometimes my dad would give me more than one cup. So that’s how I started. And then we would always go to the club and other things where people were heavily drinking. Anywhere we went with my parents, it was like a cocktail party or something. That’s the way it was.” (Age 52, non-Hispanic White, Did not reduce or quit drinking).
“My mother was a bad alcoholic. She passed away in 2006. She had quit drinking towards the end of her life and all that, but when us kids were growing up she’d even take us kids to the [name of club] and get us Shirley Temples when she drank.” (Age 50, non-Hispanic White, Quit drinking).
Other participants described acquiring knowledge and behaviors related to alcohol use, including preferences for specific types of alcohol, strategies for obtaining it, and information regarding its perceived effects, such as health benefits.
“When I was coming up, I would drink alcohol. My mama would give me alcohol, not thinking that I would become addicted to it. When I was a kid, it was good for worms. She’d send me to the store when she wasn’t able to go to the store. She’d tell me to go to the man on the corner and tell him to get her two beers. I learned how to lie, because when I got older, I went to the man and asked the man to give me four beers for me and my friends. When I got a certain age, I used my mama’s name, saying that she said to get her four beers, and since I did it for such a period of time, it was easy for the same guy to give me the alcohol. That’s when it took off.” (Age 58, non-Hispanic Black/African American, Quit drinking).
The role of peer influences on development and risk
In addition to familial influences, participants described a range of external social factors that contributed to the initiation of their alcohol use. Relationships with friends and romantic partners were frequently cited as key influences, with several participants specifically noting the role of peer pressure in prompting them to begin drinking. Others reported that the desire to fit in socially or to participate in group activities involving alcohol served as a primary motivation for their initial alcohol consumption.
“My peers, you could say peer pressure. Everybody was doing it, so I’m going to do it, too, that kind of thing.” (Age 52, non-Hispanic Black/African American, Quit drinking).
The escalation to hazardous drinking
The transition from casual to hazardous drinking was often marked by either a gradual or abrupt escalation of alcohol use, polysubstance use, and the adoption of drinking as a coping mechanism.
Escalating drinking patterns
Many participants described a gradual or sudden escalation in their drinking. Some participants described beginning with occasional drinking that gradually escalated over time, while others reported initiating alcohol use with heavy consumption and maintaining high levels of frequency and volume throughout their lives. One participant noted a specific event, retirement, that changed their life and caused them to escalate their drinking, while others just described incremental increases over time.
“Oh no, my experience is I used to not drink that much, and of course, I worked at the hospital, so I only drank on the weekends or I’d have only one beer. I drink beer mostly; once in a while, wine… Then when I retired, I got really bored and I guess depressed…So I started drinking every day, and then sometimes I would drink too much the night before, like six beers or something, and then in the morning, I’d need a beer badly, you know so that’s how that started.” (Age 52, non-Hispanic White, Did not reduce or quit drinking).
Changing drinking patterns
Some participants described having on-and-off patterns of drinking that changed during their lifetime, with specific or non-specific triggers. The on-and-off patterns described by participants varied in nature. For some, these shifts reflected transitions between periods of hazardous drinking and abstinence, often influenced by life events or changes in responsibilities. For others, the pattern involved moving between hazardous use and more moderate or controlled drinking.
“So, I stopped drinking for 13 [years], and then something hit me, and I started to have a beer. Somebody before introduced me to wine and that struck it.” (Age 39, non-Hispanic Black/African American, Reduced drinking).
Coping and mental health
Many participants reported that their alcohol use intensified as a coping mechanism for managing negative emotions. This pattern of use was frequently associated with diagnosed mental health conditions or significant adverse life experiences, suggesting a link between psychological distress and the escalation of drinking behavior.
“It made me forget the hurt. That’s where the numbness came in. I didn’t focus just on the relationship going sour. It’s like okay, it’s gone, but this drink is making me not even think about it. It’s a sense of being numb, but then covering up my true feelings of how I was feeling at that present time.” (Age 49, non-Hispanic Black/African American, Quit drinking).
“My manic depression just got a hold of me and it wouldn’t let go. It was a terrible feeling. Now they’ve got my meds regulated and everything. That’s good.” (Age 50, non-Hispanic White, Quit drinking).
In addition to using alcohol to numb negative emotions, some participants described experiencing positive emotional effects that contributed to their coping strategies. These included feelings of increased confidence, emotional release, and a temporary sense of relief from psychological distress. One participant described how the sense of empowerment they felt while drinking helped them cope with feelings of powerlessness and provided an escape from their circumstances:
“The feeling, the false image of being something that I’m not. It allowed me to speak whatever came to my mind, no filter, say how I feel. If I didn’t drink most of the things that I said I probably wouldn’t have said it sober. [Alcohol] just made me feel like superhero. I know it’s false. I know it’s due to the alcohol because I’m not the same person that I am when I’m sober. I know it’s the alcohol.” (Age 36, non-Hispanic Black/African American, Reduced drinking).
The combination of drinking and drug use
A few participants described that, as their alcohol use increased, they began using other drugs. However, some participants said that they started using alcohol as a substitute for drugs or to aid them in overcoming their drug use disorders.
“I got older, the drugs came because of the relationships I was in, trying to fit in and trying to be loved when I knew it was wrong. As I got in my twenties, I graduated to alcohol and liquor, and then I started doing drugs.” (Age 51, non-Hispanic Black/African American, Reduced drinking).
“I stopped [drinking], hooked up with this guy for a long time, he broke my heart. I didn’t want to go back in the streets to do drugs like crack and pot and that, so I went to beer, drank 15, then to 20 cans.” (Age 52, non-Hispanic Black/African American, Quit drinking).
“You know, I’ve dealt with crack, too, so you know the drinking was just like– you know, being an addict I have to have some way of relief. You know, I have to have it.” (Age 39, non-Hispanic Black/African American, Reduced drinking).
Moreover, participants generally attributed their alcohol use to its greater accessibility compared to other substances, rather than to a belief that alcohol was inherently healthier or carried fewer negative consequences. This distinction was explicitly noted by one participant, who emphasized convenience over perceived safety:
“Just because I know I can. It’s not like going to buy dope, like I’m going to get busted or anything, so it’s not scary. It’s not as scary to me going in a store and purchasing alcohol…but see, alcohol is not expensive. If you get $5, you can drink all day, compared to those shoes that you want for $50, and that cable that you got to keep on, it’s not a hard decision to make because it’s legal. It’s so easy to get that I think it’s more of how easy it is to get that makes people just drink it just to be drinking it.” (Age 36, non-Hispanic Black/African American, Reduced drinking).
Drinking continuation
Nine participants reported that they either did not reduce their alcohol consumption or continued to drink despite some reduction by the end of the study period. The reasons for continued alcohol use among WWH included emotional responses associated with drinking, its perceived impact on mental health, the social nature of alcohol consumption, and beliefs about its potential health benefits.
Alcohol’s impact on mental health
The most frequently cited reason for continued alcohol use following study participation was the emotional response associated with drinking. Many WWH talked about feeling positive, using alcohol to cope with daily stress or traumatic events, or using alcohol to relax. Some also spoke about enjoying alcohol or describing drinking and situations in which they would drink as being fun.
“I guess it’s just the atmosphere you know it loosens you up it helps you relax sometimes, and relieves a lot of tension and stress from the workday.” (Age 57, non-Hispanic Black/African American, Quit drinking).
The social aspect of drinking
Some participants reported that they continued drinking due to the social benefits it provided. Alcohol consumption was described as a means of fostering connection with friends, family members, or romantic partners. For several individuals, drinking occurred exclusively in social contexts, highlighting the role of alcohol in facilitating interpersonal relationships and social engagement.
“It’s like when you’re dealing with someone who drinks, and you want to be a part of them. You start socializing, and you find yourself drinking more often than the norm, than you would normally do. I found myself drinking.” (Age 49, non-Hispanic Black/African American, Quit drinking).
Perceived health benefits associated with drinking alcohol
Some participants said they continued to drink because they perceived health benefits from drinking. Some said they generally felt better or that drinking was part of their overall healthy routine, while others described specific situations or conditions for which they perceived benefits from drinking. However, these participants frequently describe other motivations overlapping with perceived health benefits. For instance, some participants reported not only deriving enjoyment from alcohol consumption but also perceiving functional benefits, such as improved sleep, enhanced relaxation, or relief from physical pain. This suggests that perceived health benefits may reinforce continued alcohol use and complicate efforts to reduce alcohol use, particularly when such beliefs are intertwined with emotional relief.
“Usually, I have pains when I sleep; my body hurts. I don’t sleep very well. Uh, probably before the alcohol. I heard it was caused by the alcohol, so I don’t know, but I don’t like taking pills…I’m tired of pills. So it’s like that I could take a sleeping pill instead, but I don’t. I just like drinking. [Laughs] I’m going to be honest. I just like it.” (Age 52, non-Hispanic White, Did not reduce or quit drinking).
Facilitators of successful drinking reduction
Finally, some WWH described not why they continued drinking but why they reduced or stopped. Although all participants reported hazardous drinking at the time of enrollment, several indicated that they had reduced their alcohol consumption either by the time of the interview or at some point in the past. Participants attributed their behavior change to internal motivation and personal experiences. One of these facilitators of drinking reduction was only drinking occasionally or only in specific scenarios, such as in social situations.
“It’s just I was an occasional drinker, like when I go to places, ah, when I’m hangin’ with certain people.” (Age 44, non-Hispanic Black/African American, Did not reduce or quit drinking).
Others indicated that they had a negative emotional or physical experience that prompted them to reduce or stop drinking, or that they were not getting the positive feelings and outcomes that they expected from alcohol, which made them stop drinking.
“Well, as far as experience, I don’t like the way it makes me feel anymore. I didn’t do things that I wasn’t supposed to while under the influence. I actually don’t drink as much as I used to for my own reasons. It wasn’t a good experience. It felt good when I did it, but the aftermath didn’t feel good at all because I had consequences behind it. That’s my experience.” (Age 36, non-Hispanic Black/African American, Reduced drinking).
These accounts suggest that for some WWH, drinking reduction was facilitated not by external intervention or formal support but by a personal reassessment of alcohol’s role in their lives. This reliance on internal resources highlights the importance of self-directed pathways to change.