John Mooney, Consultant in Public Health, discusses the links between alcohol and cancer at a population level and makes a case for incorporating behaviour risk profiling in relation to alcohol alongside screening targeting messaging.
The hard-hitting image of Balance North East’s ‘Alcohol is toxic’ campaign in 2023 accompanied by a graphic short video, which highlighted the links between alcohol and seven types of cancer, was clearly intended for shock value. With similarities to other shock tactic health campaigns such as graphic images of diseased lungs on cigarette packets, the strategy is known to be effective at raising awareness of health risks where these may be underappreciated in the population at large. Recently emerging compelling epidemiological evidence that alcohol is now known to markedly increase the risk of seven types of cancer [1], has prompted a reappraisal of the need for clarity in alcohol messaging so that the risks are better understood by consumers. Indeed, it is now several decades since The International Agency for Research on Cancer classified alcohol as a class one carcinogen alongside tobacco, radiation and asbestos. With cancer initiation known to be a risk from the DNA damaging potential of alcohol’s metabolic breakdown products in the body, it is clear that any beverage containing alcohol, regardless of its price and quality, poses a risk of developing cancer.
Given the degree to which alcohol consumption is normalised and celebrated as a harmless indulgence, this presents a sobering reality check if readers will excuse the pun! Of course, the well-recognised knowledge that the most sensitive organ system to the toxicity of alcohol is the body’s in-house detoxification unit, the liver, risks obscuring other significant causes of premature death, most notably cancers. Specifically, heavy alcohol consumption (i.e., ≥4 drinks/day) is associated with an increased risk of about 5-fold for oral and throat cancer as well oesophageal squamous cell carcinoma, 50% for colorectal and breast cancers, and 30% for pancreatic cancer [2]. It is also important to note that for a less common cancer (such as oesophageal cancer, even a large relative risk (that is the additional risk incurred compared to non-drinkers) may represent only a small change in the actual chance that someone will develop that cancer (that is, their absolute risk). By contrast, for a more common cancer, such as breast cancer, even a small relative risk can translate into a large absolute risk increase.
Evidence from multiple robust population health outcomes studies has further corroborated the cancer risks of alcohol consumption such that even at low intakes (i.e., ≤1 drink/day) the risk is also increased by about 20% for oral and pharyngeal cancer and 30% for oesophageal cancer. Thus, for these sites there is little evidence of a threshold effect which contributed to the WHO’s declared position in 2023 that there is no safe threshold below which there is no appreciable increase in cancer risk [3]. For some other cancers most notably pancreatic, while the increased risk is clear only for heavy alcohol consumers [4], the importance of addressing all modifiable risk factors for a cancer of steeply increasing incidence and universal high lethality has been stressed as a priority [5].
As with any high profile health topic or risk behaviour, the alcohol and cancer link is not without its fair share of myths and misinformation, often aided and abetted by commercial players for whom a wholesale adoption of safe-drinking guidelines would significantly compromise their profit margins [6]. Pre-eminent among such misconceptions has been the claim that red wine in particular could have a preventative role in some cancers, often based on animal models [7]. While the proposal is not without plausibility (based on the anti-oxidant resveratrol contained in red-wine), the finding has not been borne out by large scale population studies [8]. There are also many other plentiful dietary sources of metabolically protective nutrients in the diet that are likely to be of value in reducing the risk of many chronic diseases that arise from inflammatory origins [9].
Aside from standard public health preventative messaging around adequate exercise and optimising dietary dark coloured fruits and cruciferous vegetable, the increased cancer risk attributable to alcohol should also ideally be informing what might be referred to as secondary prevention activities such as cancer screening programmes. Since we know that breast and bowel cancer screening are undoubtedly worthwhile for their capacity to detect cancers early, their targeting criteria are currently focused predominantly on demographic factors and rarely on behavioural risk factors. Given that alcohol consumption for instance is now among the leading risk factors for breast cancer, even at relatively low levels of consumption [10], combined with an under-appreciation of the cancer risks associated with alcohol [11], there is clearly a case to be made for incorporating behaviour risk profiling in relation to alcohol alongside screening targeting messaging. Such a move might also help address the profound social patterning of cancer survival rates versus detection rates with the least socially advantaged groups faring much worse on survival.
1. Anderson BO, Berdzuli N, Ilbawi A, Kestel D, Kluge HP, Krech R, Mikkelsen B, Neufeld M, Poznyak V, Rekve D et al: Health and cancer risks associated with low levels of alcohol consumption. The Lancet Public Health 2023, 8(1):e6-e7.
2. Pelucchi C, Irene T, Paolo B, Eva N, and Vecchia CL: Alcohol Consumption and Cancer Risk. Nutrition and Cancer 2011, 63(7):983-990.
3. World Health Organisation: No level of alcohol consumption is safe for our health. In.; 2023.
4. Tramacere I, Scotti L, Jenab M, Bagnardi V, Bellocco R, Rota M, Corrao G, Bravi F, Boffetta P, La Vecchia C: Alcohol drinking and pancreatic cancer risk: a meta‐analysis of the dose‐risk relation. International journal of cancer 2010, 126(6):1474-1486.
5. Klein AP: Pancreatic cancer: a growing burden. The Lancet Gastroenterology & Hepatology 2019, 4(12):895-896.
6. Movendi International: UK: Big Alcohol Earns £11bn From Higher Risk Alcohol Use Yearly, Government Action Needed. In: Policy Update. Movendi; 2023.
7. Cai H, Scott E, Kholghi A, Andreadi C, Rufini A, Karmokar A, Britton RG, Horner-Glister E, Greaves P, Jawad D et al: Cancer chemoprevention: Evidence of a nonlinear dose response for the protective effects of resveratrol in humans and mice. Science Translational Medicine 2015, 7(298):298ra117-298ra117.
8. Chao C, Reina H, J. CB, T. PK-Y, Hung-Fu T, and Quinn VP: Red Wine Consumption Not Associated With Reduced Risk of Colorectal Cancer. Nutrition and Cancer 2010, 62(6):849-855.
9. El Gharras H: Polyphenols: food sources, properties and applications – a review. International Journal of Food Science and Technology 2009, 44(12):2512-2518.
10. Shield KD, Soerjomataram I, Rehm J: Alcohol Use and Breast Cancer: A Critical Review. Alcoholism: Clinical and Experimental Research 2016, 40(6):1166-1181.
11. Bates S, Holmes J, Gavens L, de Matos EG, Li J, Ward B, Hooper L, Dixon S, Buykx P: Awareness of alcohol as a risk factor for cancer is associated with public support for alcohol policies. BMC Public Health 2018, 18(1):688.
SHAAP Blogposts are published with the permission of the authors. The views expressed are solely the authors’ own and do not necessarily represent the views of Scottish Health Action on Alcohol Problems (SHAAP).
John Mooney
John is currently employed as a consultant in public health for NHS Grampian where his remit includes drugs and alcohol as well as TB and blood borne viruses. He is also a member of SHAAP’s Steering Group.
Originally trained in biochemistry and pharmacology at the University of Strathclyde, John completed an MPH on a Carnegie scholarship at the University of Glasgow after being inspired by working in grassroots community health projects. After five years at Health Protection Scotland specialising in the epidemiology of respiratory infectious diseases, John undertook FPH Specialist training which he completed in 2009. Since qualifying he has mainly been based in academic roles but always with strong links (including P/T attachments), to public health teams and departments from local councils and NHS Boards through to Public Health England and an MRC Fellowship at the Scottish Collaboration for Public Health Research & Policy. During and since qualifying, John has maintained a strong interest in harm prevention policies and interventions for alcohol and substance misuse and was awarded the Faculty of Public Health’s President’s Medal in 2020, in recognition of his research and policy translation work in this area.