Alcohol problems have long been more common in men, but rates in women are rising, and women tend to develop complications faster than men. It has been suggested also that women and men may drink for different reasons, with women more likely to drink to relieve negative emotional states and men for pleasurable, rewarding effects. The researchers used a well-controlled laboratory paradigm to explore these potential differences.
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Alcohol use disorder has historically been more prevalent in men; however, problematic alcohol use is increasingly prevalent in women, with heavy drinking women tending to experience a more rapid onset of alcohol related problems. Though there is a lot of variability within groups of women and men, studies suggest that on average, women and men with a drinking problem differ in their motivations to drink, with women being more likely to drink to relieve negative emotional states (e.g., anxiety, symptoms of depression) – which are also known to be more common among women than men – and as a result experience ‘relief craving’, while men are more likely to seek pleasurable (i.e., hedonic) reward through alcohol and experience ‘reward craving’.
Processes like relief and reward craving can be measured through subjective self-report as well as objective psychophysiological measures. Heart rate variability—the subtle moment-to-moment changes in heart rate in response to situational demands—is an indicator of autonomic activity. Greater heart rate variability generally signals a calm, flexible nervous system, while lower heart rate variability often reflects a stress response. Previous research has shown heart rate variability changes in response to craving, though how it changes (i.e., increases, decreases) tends to vary by context.
In this study, the researchers sought to better understand potential sex differences in alcohol craving among heavy drinking women and men using self-report and heart rate variability. They speculated that because women are more likely to experience ‘relief craving’, which could be thought of as a stress response, they would experience reduced heart rate variability in response to alcohol cues, while men would show an increase in heart rate variability reflecting a reward craving.
This was a laboratory-based cue-reactivity study with 114 people experiencing problems related to alcohol who were exposed to a series of alcohol cues while they self-reported craving and their heart rate variability was monitored.
Participants completed a standardized, ~5-minute alcohol cue-reactivity protocol that included: 1) guided relaxation (75 sec), 2) viewing alcohol pictures (4 x 30 sec blocks), 3) a scripted alcohol-related imagery task (2 x 30 sec scripts), and 4) handling a real alcoholic beverage (remove from container, pour, smell, sip; 30 sec each). They self-reported relief and reward craving during each task using the Desire for Alcohol Questionnaire. Average heart rate variability was calculated for each task from continuously recorded electrocardiogram (ECG).
Participants (61 women and 53 men) were recruited from the University of Amsterdam and local community, and were young, on average, 22 years old (range 18 to 40), with a median Alcohol Use Disorder Identification Test (AUDIT) score of 18, indicative of high-risk/harmful drinking and probable alcohol use disorder for the average participant.
Self-reported craving increased for everyone
Both relief and reward craving rose with each alcohol exposure task, but contrary to what the researchers predicted, there were no sex differences in the kind or magnitude of self-reported craving across tasks.
Heart rate variability dropped for both sexes during cue exposure
Heart rate variability decreased in response to alcohol cues for both sexes and returned to near relaxation-baseline levels during handling/sipping alcohol. Though both women and men showed a similar pattern of responding, men experienced a greater decline in heart rate variability during the picture phase, relative to women.
Relief craving was associated with a stress-like response
Regardless of whether participants self-reported high or low relief craving in response to alcohol cues, heart rate variability decreased during both alcohol picture exposure and imagery exposure but decreased to a greater degree for the high relief craving group. This pattern suggests greater stress and engagement with the cue exposure task; importantly, however, the pattern did not differ by sex.
The study findings suggest young women and men who drink at harmful levels experience both relief and reward craving at similar levels when exposed to alcohol cues, and that this is characterized by an autonomic stress response (regardless of craving type). Though not reported in this study, this is in contrast to how healthy control participants tend to respond to alcohol cue-reactivity paradigms. They tend to experience less subjective craving with increases in heart rate variability in response to alcohol cues, consistent with attention allocation or emotional engagement rather than stress.
The only sex difference observed by the researchers was that men exhibited greater autonomic reactivity during cue-elicited craving, despite reporting similar craving intensity as women. This difference may reflect heightened attentional capture operating outside conscious awareness that could in turn increase vulnerability to cue-driven alcohol seeking and use among men.
Notably, heart rate variability increased to near relaxation-baseline levels in both groups when handling alcohol, suggesting a resolution of craving, however, the researchers did not report the raw craving scores during each study task so it can’t be known if this was the case.
Although relief versus reward craving did not vary by sex in this cue-reactivity study, sex differences could appear in other contexts. Cue-reactivity paradigms like this have the benefit of tight experimental control, but their laboratory settings limit generalizability to real-world alcohol exposure and drinking situations. These findings should be considered in light of this limitation.
Results should also be considered in light of the fact participants were young (early 20s on average), with less chronic patterns of intensive alcohol exposure, and had Alcohol Use Disorder Identification Test scores indicative of harmful/high-risk drinking. Results may not generalize to older, more chronic and intensive cases, or even drinkers of similar age but who suffer from more severe alcohol use disorder.
Young women and men with a drinking problem may be more similar than different in terms of their experience of relief and reward craving for alcohol, though men may experience greater physiological stress in response to alcohol cues. More work is needed to understand if or how these findings generalize to other age and severity/chronicity alcohol groups as well as real-world scenarios.
Firdaus, I., Huizink, A. C., Kleiboer, A., Goudriaan, A. E., & Kaag, A. M. (2025). Gender differences in alcohol-cue-induced craving and heart-rate variability in hazardous drinkers. Drug and Alcohol Dependence, 271. doi: 10.1016/j.drugalcdep.2025.112662.
l
Alcohol use disorder has historically been more prevalent in men; however, problematic alcohol use is increasingly prevalent in women, with heavy drinking women tending to experience a more rapid onset of alcohol related problems. Though there is a lot of variability within groups of women and men, studies suggest that on average, women and men with a drinking problem differ in their motivations to drink, with women being more likely to drink to relieve negative emotional states (e.g., anxiety, symptoms of depression) – which are also known to be more common among women than men – and as a result experience ‘relief craving’, while men are more likely to seek pleasurable (i.e., hedonic) reward through alcohol and experience ‘reward craving’.
Processes like relief and reward craving can be measured through subjective self-report as well as objective psychophysiological measures. Heart rate variability—the subtle moment-to-moment changes in heart rate in response to situational demands—is an indicator of autonomic activity. Greater heart rate variability generally signals a calm, flexible nervous system, while lower heart rate variability often reflects a stress response. Previous research has shown heart rate variability changes in response to craving, though how it changes (i.e., increases, decreases) tends to vary by context.
In this study, the researchers sought to better understand potential sex differences in alcohol craving among heavy drinking women and men using self-report and heart rate variability. They speculated that because women are more likely to experience ‘relief craving’, which could be thought of as a stress response, they would experience reduced heart rate variability in response to alcohol cues, while men would show an increase in heart rate variability reflecting a reward craving.
This was a laboratory-based cue-reactivity study with 114 people experiencing problems related to alcohol who were exposed to a series of alcohol cues while they self-reported craving and their heart rate variability was monitored.
Participants completed a standardized, ~5-minute alcohol cue-reactivity protocol that included: 1) guided relaxation (75 sec), 2) viewing alcohol pictures (4 x 30 sec blocks), 3) a scripted alcohol-related imagery task (2 x 30 sec scripts), and 4) handling a real alcoholic beverage (remove from container, pour, smell, sip; 30 sec each). They self-reported relief and reward craving during each task using the Desire for Alcohol Questionnaire. Average heart rate variability was calculated for each task from continuously recorded electrocardiogram (ECG).
Participants (61 women and 53 men) were recruited from the University of Amsterdam and local community, and were young, on average, 22 years old (range 18 to 40), with a median Alcohol Use Disorder Identification Test (AUDIT) score of 18, indicative of high-risk/harmful drinking and probable alcohol use disorder for the average participant.
Self-reported craving increased for everyone
Both relief and reward craving rose with each alcohol exposure task, but contrary to what the researchers predicted, there were no sex differences in the kind or magnitude of self-reported craving across tasks.
Heart rate variability dropped for both sexes during cue exposure
Heart rate variability decreased in response to alcohol cues for both sexes and returned to near relaxation-baseline levels during handling/sipping alcohol. Though both women and men showed a similar pattern of responding, men experienced a greater decline in heart rate variability during the picture phase, relative to women.
Relief craving was associated with a stress-like response
Regardless of whether participants self-reported high or low relief craving in response to alcohol cues, heart rate variability decreased during both alcohol picture exposure and imagery exposure but decreased to a greater degree for the high relief craving group. This pattern suggests greater stress and engagement with the cue exposure task; importantly, however, the pattern did not differ by sex.
The study findings suggest young women and men who drink at harmful levels experience both relief and reward craving at similar levels when exposed to alcohol cues, and that this is characterized by an autonomic stress response (regardless of craving type). Though not reported in this study, this is in contrast to how healthy control participants tend to respond to alcohol cue-reactivity paradigms. They tend to experience less subjective craving with increases in heart rate variability in response to alcohol cues, consistent with attention allocation or emotional engagement rather than stress.
The only sex difference observed by the researchers was that men exhibited greater autonomic reactivity during cue-elicited craving, despite reporting similar craving intensity as women. This difference may reflect heightened attentional capture operating outside conscious awareness that could in turn increase vulnerability to cue-driven alcohol seeking and use among men.
Notably, heart rate variability increased to near relaxation-baseline levels in both groups when handling alcohol, suggesting a resolution of craving, however, the researchers did not report the raw craving scores during each study task so it can’t be known if this was the case.
Although relief versus reward craving did not vary by sex in this cue-reactivity study, sex differences could appear in other contexts. Cue-reactivity paradigms like this have the benefit of tight experimental control, but their laboratory settings limit generalizability to real-world alcohol exposure and drinking situations. These findings should be considered in light of this limitation.
Results should also be considered in light of the fact participants were young (early 20s on average), with less chronic patterns of intensive alcohol exposure, and had Alcohol Use Disorder Identification Test scores indicative of harmful/high-risk drinking. Results may not generalize to older, more chronic and intensive cases, or even drinkers of similar age but who suffer from more severe alcohol use disorder.
Young women and men with a drinking problem may be more similar than different in terms of their experience of relief and reward craving for alcohol, though men may experience greater physiological stress in response to alcohol cues. More work is needed to understand if or how these findings generalize to other age and severity/chronicity alcohol groups as well as real-world scenarios.
Firdaus, I., Huizink, A. C., Kleiboer, A., Goudriaan, A. E., & Kaag, A. M. (2025). Gender differences in alcohol-cue-induced craving and heart-rate variability in hazardous drinkers. Drug and Alcohol Dependence, 271. doi: 10.1016/j.drugalcdep.2025.112662.
l
Alcohol use disorder has historically been more prevalent in men; however, problematic alcohol use is increasingly prevalent in women, with heavy drinking women tending to experience a more rapid onset of alcohol related problems. Though there is a lot of variability within groups of women and men, studies suggest that on average, women and men with a drinking problem differ in their motivations to drink, with women being more likely to drink to relieve negative emotional states (e.g., anxiety, symptoms of depression) – which are also known to be more common among women than men – and as a result experience ‘relief craving’, while men are more likely to seek pleasurable (i.e., hedonic) reward through alcohol and experience ‘reward craving’.
Processes like relief and reward craving can be measured through subjective self-report as well as objective psychophysiological measures. Heart rate variability—the subtle moment-to-moment changes in heart rate in response to situational demands—is an indicator of autonomic activity. Greater heart rate variability generally signals a calm, flexible nervous system, while lower heart rate variability often reflects a stress response. Previous research has shown heart rate variability changes in response to craving, though how it changes (i.e., increases, decreases) tends to vary by context.
In this study, the researchers sought to better understand potential sex differences in alcohol craving among heavy drinking women and men using self-report and heart rate variability. They speculated that because women are more likely to experience ‘relief craving’, which could be thought of as a stress response, they would experience reduced heart rate variability in response to alcohol cues, while men would show an increase in heart rate variability reflecting a reward craving.
This was a laboratory-based cue-reactivity study with 114 people experiencing problems related to alcohol who were exposed to a series of alcohol cues while they self-reported craving and their heart rate variability was monitored.
Participants completed a standardized, ~5-minute alcohol cue-reactivity protocol that included: 1) guided relaxation (75 sec), 2) viewing alcohol pictures (4 x 30 sec blocks), 3) a scripted alcohol-related imagery task (2 x 30 sec scripts), and 4) handling a real alcoholic beverage (remove from container, pour, smell, sip; 30 sec each). They self-reported relief and reward craving during each task using the Desire for Alcohol Questionnaire. Average heart rate variability was calculated for each task from continuously recorded electrocardiogram (ECG).
Participants (61 women and 53 men) were recruited from the University of Amsterdam and local community, and were young, on average, 22 years old (range 18 to 40), with a median Alcohol Use Disorder Identification Test (AUDIT) score of 18, indicative of high-risk/harmful drinking and probable alcohol use disorder for the average participant.
Self-reported craving increased for everyone
Both relief and reward craving rose with each alcohol exposure task, but contrary to what the researchers predicted, there were no sex differences in the kind or magnitude of self-reported craving across tasks.
Heart rate variability dropped for both sexes during cue exposure
Heart rate variability decreased in response to alcohol cues for both sexes and returned to near relaxation-baseline levels during handling/sipping alcohol. Though both women and men showed a similar pattern of responding, men experienced a greater decline in heart rate variability during the picture phase, relative to women.
Relief craving was associated with a stress-like response
Regardless of whether participants self-reported high or low relief craving in response to alcohol cues, heart rate variability decreased during both alcohol picture exposure and imagery exposure but decreased to a greater degree for the high relief craving group. This pattern suggests greater stress and engagement with the cue exposure task; importantly, however, the pattern did not differ by sex.
The study findings suggest young women and men who drink at harmful levels experience both relief and reward craving at similar levels when exposed to alcohol cues, and that this is characterized by an autonomic stress response (regardless of craving type). Though not reported in this study, this is in contrast to how healthy control participants tend to respond to alcohol cue-reactivity paradigms. They tend to experience less subjective craving with increases in heart rate variability in response to alcohol cues, consistent with attention allocation or emotional engagement rather than stress.
The only sex difference observed by the researchers was that men exhibited greater autonomic reactivity during cue-elicited craving, despite reporting similar craving intensity as women. This difference may reflect heightened attentional capture operating outside conscious awareness that could in turn increase vulnerability to cue-driven alcohol seeking and use among men.
Notably, heart rate variability increased to near relaxation-baseline levels in both groups when handling alcohol, suggesting a resolution of craving, however, the researchers did not report the raw craving scores during each study task so it can’t be known if this was the case.
Although relief versus reward craving did not vary by sex in this cue-reactivity study, sex differences could appear in other contexts. Cue-reactivity paradigms like this have the benefit of tight experimental control, but their laboratory settings limit generalizability to real-world alcohol exposure and drinking situations. These findings should be considered in light of this limitation.
Results should also be considered in light of the fact participants were young (early 20s on average), with less chronic patterns of intensive alcohol exposure, and had Alcohol Use Disorder Identification Test scores indicative of harmful/high-risk drinking. Results may not generalize to older, more chronic and intensive cases, or even drinkers of similar age but who suffer from more severe alcohol use disorder.
Young women and men with a drinking problem may be more similar than different in terms of their experience of relief and reward craving for alcohol, though men may experience greater physiological stress in response to alcohol cues. More work is needed to understand if or how these findings generalize to other age and severity/chronicity alcohol groups as well as real-world scenarios.
Firdaus, I., Huizink, A. C., Kleiboer, A., Goudriaan, A. E., & Kaag, A. M. (2025). Gender differences in alcohol-cue-induced craving and heart-rate variability in hazardous drinkers. Drug and Alcohol Dependence, 271. doi: 10.1016/j.drugalcdep.2025.112662.
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