Public awareness of the alcohol-cancer link in the EU and UK: a scoping review

Abstract

Background

Alcohol increases cancer risk, but less is known about public awareness of this link. This scoping review summarizes recent findings on the public awareness of alcohol as a cancer risk factor in European Union and UK.

Methods

Four databases (Web of Science, MEDLINE, PsycInfo, CINAHL) were searched for papers containing data on awareness of alcohol as cancer risk factor in EU or UK published between January 2017 and December 2022, and complemented with grey literature searches.

Results

In total, 45 studies were included covering 18 EU countries (Austria, Belgium, Cyprus, Czechia, Denmark, Finland, France, Germany, Hungary, Ireland, Italy, Netherlands, Poland, Romania, Slovakia, Slovenia, Spain, Sweden) and UK, presenting data collected between 2009 and 2022. Studies covered general population (17 studied a nationally representative sample), women, health professionals, patients and young people. Awareness of alcohol causing cancer in general was higher and studied more often than awareness of alcohol’s impact on specific cancers. Among the EU general population, awareness of the link between alcohol and breast cancer ranged between 10% and 20%, head and neck cancer 15–25%, colorectal and oesophagus cancer 15–45% and liver cancer 40%. Awareness was higher among young people and specialized health professions and lower among women (the latter specifically for the breast cancer).

Conclusions

While awareness rates varied depending on the exact question wording, many studies showed low awareness of the alcohol-cancer link, especially for specific types such as breast and colon cancer. Public should be better informed about alcohol consumption-related cancer risk.

Introduction

Alcohol is a Group 1 carcinogen by the International Agency for Research on Cancer (IARC), establishing highest level of causal evidence for the relationship with cancer.^1,2 Alcohol consumption is causally related to oesophageal, liver, larynx, female breast, colon and rectum, lip and oral cavity and other pharynx cancer.³ Ethanol is a procarcinogen, as it transforms into a carcinogen by metabolism,¹ causing cancer via mechanisms such as metabolizing of ethanol into acetaldehyde, resulting in DNA damage and blocking DNA synthesis and repair.⁴ No protective effect is seen at any alcohol use level, and risk increases with increased consumption.^5,6 The World Health Organization European Region has higher consumption compared to other regions and high alcohol-attributable disease burden, including cancer.⁷ IARC data from 2020 show 4.5% of all new cancer cases in Europe were attributable to alcohol consumption, with one tenth of those cases due to light-to-moderate drinking (up to 20 g of pure alcohol per day).^8,9

Despite the alcohol classified as carcinogen already in 1988, this is not fully reflected in public awareness. Recent studies in Canada, USA and Australia showed 25–50% of respondents aware of this link.^10–13 Current information on public awareness in the European Union (EU) is scattered through different sources and not systematically appraised. In the 2009 Eurobarometer,¹⁴ 36% respondents totally agreed alcohol can increase risk of cancer, and 31% tended to agree. A systematic review covering studies up to 2017,¹⁵ found low awareness levels in Europe: 43% in Denmark and 47% in Sweden in 2011,¹⁶ 24.6% in Portugal in 2013,¹⁷ 42% in Ireland in 2015¹⁸ and 12.9% in the UK in 2016.¹⁹ Overall, the review also found that awareness was generally lower when questions were unprompted (asking e.g. ‘What diseases are caused by alcohol?’) rather than prompted (e.g. ‘Do you think that alcohol can increase cancer risk?’).¹⁵

The present review aims to summarize the recent evidence on the awareness of alcohol as a risk factor for cancer in the European Union and the UK. The specific sub-questions this review will answer are:

• What is the awareness of the causal link between alcohol and cancer, including specific cancers?

• What is the awareness of the causal link between alcohol and cancer in the general population, and in any specific subpopulations (e.g. young people, health professionals)?

• Does the awareness differ based on the question format (prompted/unprompted)?

Methods

Design

We used scoping review methodology due to research questions’ breadth and focus on several target groups and outcomes. Scoping reviews are used to map the main concepts in the research area and present a broad overview of the existing evidence, including identification of the gaps, regardless of the study quality.²⁰ Design was guided by Arksey and O’Malley’s methodological framework.²¹ Results are reported in line with the PRISMA extension for scoping reviews.²²

Eligibility criteria

For inclusion in the review, the studies had to employ quantitative methods, include information on the awareness of the link between alcohol and cancer, and cover EU or UK population. Literature published in 2017 or after was included, as the earlier literature was covered in the review by Scheideler and Klein.¹⁵ Both peer-reviewed and grey literature in any European language were eligible for inclusion.

Information sources and search strategy

Four databases (Web of Science, MEDLINE, PsycInfo, CINAHL) were searched in February 2022 and updated in December 2022 with the abovementioned restrictions on date (2017 or after). Search strategy contained combination of terms related to awareness of alcohol and cancer and eligible countries (example strategy for PubMed: [(Knowledge OR awareness) AND alcohol AND cancer AND (Europe* OR Austria OR Belgium OR Bulgaria OR Croatia OR Cyprus OR Czech* OR Denmark OR Estonia OR Finland OR France OR Germany OR Greece OR Hungary OR Ireland OR Italy OR Latvia OR Lithuania OR Luxembourg OR Malta OR Netherlands OR Poland OR Portugal OR Romania OR Slovakia OR Slovenia OR Spain OR Sweden OR United Kingdom OR Britain OR Scotland OR England OR Wales Or Northern Ireland)]. Reference lists of identified articles and any relevant reviews were inspected for further literature. Additionally, grey literature databases (greylit.org, opengrey.eu), Google Scholar and Google were used to search for grey literature (national reports, international surveys) with simplified versions of the search strategy used for database search, and individual public health experts in the countries were contacted to help identify reports on national level.

Study selection and summary

The study selection was performed by one researcher (D.K.) according to abovementioned inclusion criteria. After removal of duplicates, the studies were screened by title and abstract, followed by full text examination and final article selection. Any doubts were resolved through discussion with the second researcher (M.N.). The full data from the selected articles were extracted by one researcher, with second researcher separately extracting the awareness data of the papers to ensure accuracy. The data extraction form contained information on authors, year of publication, paper objectives, country, population, sample information, methodology used (including how the question was posed), type of cancer and key findings or conclusions. In case of information in the paper not being sufficiently clear, the corresponding authors were contacted by e-mail to provide further clarification.

Ethics

No primary data were collected.

Results

Study characteristics

In total, we found 45 sources (35 peer-reviewed publications and 10 grey literature sources) published between January 2017 and December 2022 and involving information on alcohol and cancer awareness (PRISMA diagram and full list of references available in Supplementary material).^41–85 The studies involved data from 18 EU countries (Austria, Belgium, Cyprus, Czechia, Denmark, Finland, France, Germany, Hungary, Ireland, Italy, Netherlands, Poland, Romania, Slovakia, Slovenia, Spain, Sweden) and the UK (overall, England and Scotland) (Table 1). Studies predominantly employed cross-sectional design—self-administered, computer assisted or online surveys with data collected between 2009 and 2022 (with the majority of the data collected 2015 or after). Three studies were evaluating effects of a mass media campaign and thus included information for several time points,^44,65,80 one study was evaluating an educational intervention⁶⁷ and one study evaluated health warning labels.⁷¹ Twenty-four studies examined awareness of the general alcohol cancer link.^{42–45,50,51,53,55,62,65,68,70,71,74–76,78–82,84,85} Twenty studies examined awareness of the link of alcohol with head and neck cancer (comprising also oral, mouth and throat cancer)^{44,47,49,52,55–60,63,65–67,72,73,77–79,83} and 12 studies examined awareness of the link between alcohol and breast cancer.^{41,44,46,48,54,55,57,61,64,65,78,79} Eight studies examined colon cancer awareness^{44,55,57,61,65,69,78,79} and six studies each examined awareness of link between alcohol and liver^{44,51,55,65,78,79}or oesophagus cancer.^{44,55,57,65,78,79}

Table 1.

Study characteristics

Authors	Year of data collection	Country	Study aim	Study design	Sample characteristics	Type of population	Nationally representative sample
Agabio et al. (2021) 41	2020	Italy	To investigate the awareness of relationship between alcohol and breast cancer among Italian women attending breast screening programmes.	Cross-sectional study; survey interview by phone or video call	N = 507, 100% female	Women	No
Bates et al. (2018) 42	2015	UK (England)	To investigate the relationship between awareness of the alcohol-cancer link and support for a range of alcohol policies in an English sample and policy context.	Cross-sectional study; online survey	N = 2100, 51% female	General population 18+	Yes
Behrens, Lundgaard and Christensen (2022) 78	2020	Denmark	To examine drinking habits, knowledge and attitudes to alcohol.	Cross-sectional survey	N = 3000 (50.1% female)	General population (18–74)	Yes
Bocquier et al. (2017) 43	2010	France	To examine French people’s beliefs about the risks of alcohol, their correlates, and their associations with alcohol use.	Cross-sectional telephone survey (Barometre Cancer survey)	N = 3359, 51% female	General population 15+	Yes
Braekman and Fiers (2022) 82	2022	Belgium (Flanders)	Part of ‘Preventiebarometer’ study with focus on alcohol consumption, intentions, attitudes and knowledge.	Cross-sectional survey	N = 4.011 (18+)	General population (18+)	Yes
Bujalski and Stokwiszewski (2021) 81	2019	Poland	To investigate how specific beliefs about alcohol along with alcohol-related experiences relate to personal and general alcohol risk perceptions in Poland.	Cross-sectional survey	N = 2000 (50.1% female)	General population	Yes
Christensen et al. (2019) 44	T1: 2017 T2: 2018	Denmark	To test whether a mass media campaign intended to raise awareness of the relation between alcohol and cancer is associated with higher public awareness of alcohol as a risk factor for cancer, and higher levels of support for alcohol related policies.	Two cross-sectional surveys done through an online panel	T1: N = 3000, 50% female T2: N = 3000, 49% female	General population 18+	Yes
Davies et al. (2022) 74	2017–2018	Austria, Belgium, Czech Republic, Denmark, England, Finland, France, Germany, Hungary, Italy, Ireland, Netherlands, Poland, Scotland, Slovakia, Spain, Sweden	To explore responses to alcohol health information labels from a cross sectional survey of people who drink alcohol from 29 countries.	Cross-sectional study, online survey	N = 75969 (64.3% male)	General population (psychoactive substance consumers)	No
Di Giuseppe et al. (2020) 45	2019–2020	Italy	To explore knowledge, attitudes and lifestyle behaviours related to cancer in a sample of adolescents.	Cross sectional survey, self-administered questionnaire	N = 871; no info on % female M age = 15.7 (age range 13–20)	Adolescents (high school)	No
Firincioglulari et al. (2022) 58	Not mentioned	Cyprus (North Cyprus)	To evaluate the awareness and knowledge levels on oral cancer symptoms and risk factors among patients attending a faculty of dentistry in North Cyprus.	Cross-sectional survey, self-administered questionnaire	N = 250, 45.2% female	Attendees of dental clinic	No
Fisher et al. (2017) 46	2013–2014	UK (England)	To measure breast cancer screening attendees’ interest in having a personal risk assessment, expected impact on screening attendance, knowledge of associations between lifestyle and breast cancer and preferred ways of accessing preventative lifestyle advice.	Cross-sectional study, self-complete postal survey	N = 1803, 100% female M age = 57.8	Women	No
Foucaud et al. (2018) 70	2015	France	To investigate the representations of the general population and of subjects who have or have had cancer in relation to this disease and the perception of risk factors.	Cross-sectional telephone survey (Barometre Cancer survey)	N = 3,817; 51% female	General population 15–75	Yes
Frola and Barrios (2017) 66	2015	Spain	To explore oral cancer knowledge and attitudes among dental students of Granada after the implementation of the Bologna plan.	Cross-sectional study; self-administered pen-and-paper questionnaire	N = 121; 67.8% female M age = 23.4 ± 2.9	University dentistry students	No
Gerber et al. (2022) 83	Between 2013 and 2021	Poland and Germany	To investigate the levels of public awareness about the early symptoms and risk factors of oral cancer.	Cross-sectional survey	N = 454 (18–95 age range) (64.5% females) PL: 314, DE: 140	Patients	No
Hansen, Lundgaard and Christensen (2022) 79	2021	Denmark	To map the alcohol habits in 2021 among young people aged 15–25.	Cross-sectional survey	N = 1015	Young people (15–25)	Yes
Kawecki et al. (2019) 47	2009–2010	UK (Scotland)	To determine the level of mouth cancer awareness and to investigate the associated factors in a United Kingdom (UK) general population sample.	Cross-sectional study, self-complete postal survey (Adult Dental Health Survey)	N = 3022, 53.2% female	General population 25+	Representative of Scotland
Kelly and Richmond (2018) 62	2015	Ireland	To investigate cancer survivors’ knowledge about the risk factors for cancer, examine their perception of their personal risk, and assess their motivation for lifestyle change.	Cross-sectional study, self-administered questionnaire	N = 414, 72.9% female M age = 60 (age range 22–89)	Cancer survivors (adults who completed acute cancer treatment for a solid cancer)	No
Koczkodaj et al. (2019) 48	2017	Poland	To investigate women’s awareness and attitudes to breast cancer risk factors in Poland.	Cross-sectional study, CAWI (Computer-Assisted Web Interview) and PAPI (Paper and Pen Personal Interview) methodology	N = 380, 100% female	Women 45+	No
Košir et al. (2020) 85	Not mentioned	Slovenia	To determine how well are the teenagers aware of the cancer risk factors.	Cross-sectional survey; questionnaire delivered in school	N = 185, 46% female Age range 12–15 years	Adolescents (elementary school)	No
Krentowska et al. (2018) 49	2014–2015	Poland	To evaluate the level of head and neck cancer awareness in the young population in Poland.	Cross-sectional study, online survey	N = 1903, 73.5% female	Young adults (18–35)	No
Leuci et al. (2022) 72	2021	Italy	To explore knowledge, practice, and attitude on oral cancer (OC) among a cohort of Italian dental hygienists.	Cross-sectional study	N = 137 60.6% female	Healthcare professionals	No
Lotrean et al. (2021) 50	2017	Romania	To assess the opinions and behaviour related to healthy lifestyle and cancer prevention among Romanian university students.	Cross-sectional study, self-administered questionnaires	N = 400	University students	No
Luckman et al. (2017) 51	2015	UK	To assess the knowledge of lifestyle factors and cancer in undergraduate medical students.	Cross-sectional online survey	N = 218, Mage = 21 (range 18–32)	University medical students	No
Martin et al. (2018) 65	2015	UK (North East England)	To examine the relationship between a mass media campaign, awareness of the link between alcohol and cancer, intention to reduce alcohol consumption and support for alcohol related policies.	Three cross-sectional surveys done on street, face to face interviews	N = 572 T1 N = 576 T2 N = 552 T3 52% female (weighted sample across all waves)	General population 18+	No
Morere et al. (2018) 64	2014	France	To investigate the knowledge of breast cancer risk factors among laywomen and female physicians.	Cross-sectional study, phone survey (EDIFICE 4)	N (laywomen) = 737 N (physicians) = 105 Age range = 40–75	Women (general population and physicians)	No
Morgernstern et al. (2021) 71	2017/2018	Germany	To examine the effects of warning labels on knowledge, negative emotions and self-reported alcohol consumption.	Three factorial experiment	N = 9260 M age = 12.9 ± 1.8, range 10–17 years 48.6% female	Secondary school students	No
Murariu et al. (2022) 73	2022	Romania	To assess dental students’ and residents’ levels of awareness in terms of oral cancer.	Cross-sectional study	N = 197 M age = 25.0 ± 4.9, range 21–43 years 64% female	Dentistry students and residents	No
National Cancer Control Programme (NCCP) 84	2022	Ireland	To assess beliefs about cancer, asses knowledge of cancer signs, and assess health seeking behaviour.	Cross-sectional study; phone survey	N = 2874; 51% female	General population 18+	Yes
Nocini et al. (2020) 52	2019–2020	Italy	To assess oral squamous cell carcinoma awareness and attitudes among general population.	Cross-sectional study; online survey	N = 505, 71.5% female 71% under 35 years old	General population 18+	No
O’Dwyer et al. (2021) 61	2015–2016	Ireland	To explore public awareness of the association between alcohol use and the risk of developing five alcohol-related health conditions: liver disease, pancreatitis, high blood pressure, female breast cancer, and bowel cancer.	Cross-sectional study, Wave 2 of Healthy Ireland Survey, face to face, computer assisted interviews in respondents homes	N = 7498 56% female 22% 15–34, 52% 35–64, 26% 65+	General population 15+	Yes
Pérez-González et al. (2022) 59	Not mentioned	Spain	To analyse alcohol consumption, as well as to consider the knowledge and attitudes regarding morbidity, and the stage of change among healthcare students.	Cross-sectional study, combination of on site and online survey	N = 500, 72.2% female M age = 20.7	Dentistry and Medical students	No
Petrova et al. (2021) 53	2020	Spain	To describe the perceived influence of four lifestyle factors (tobacco, alcohol, diet, and weight) on cancer development in the general population and identify factors related to low perceptions of influence.	Cross-sectional study, CAWI survey, 2020 Onco-barometer 2020	N = 4769, 56.5% female	General population 18+	Yes
Pinkas et al. (2022) 60	2021	Poland	To assess the public awareness of head and neck cancer (HNC) among adults in Poland, with particular emphasis on awareness of HNC symptoms and risk factors for HNC.	Cross-sectional study, CAWI survey	N = 1082, 52.6% female, Mage = 44.5	General Population 18+	Yes
Quatremère et al. (2022) 80	2019	France	To evaluate the effectiveness of a French mass-media campaign in raising knowledge of both long-term alcohol-related harms (LTH) and low-risk drinking guidelines (LRDG), as well as in lowering alcohol consumption.	Longitudinal survey (three waves)	N = 2538 (age range 18–75) 49.6% female	General population (drinkers only)	No
Rupel et al. (2020) 67	Not mentioned	Italy	To test the awareness and increase in knowledge of oral cancer and its risk factors among young preadolescents after a lecture.	Pre-post design; self-administered pen-and-paper questionnaire	N = 460 Age range: 12–14 years	Middle-school students	No
Schouten et al. (2021) 57	2020	The Netherlands	To investigate the level of knowledge of the personal and social consequences of alcohol use; the knowledge of the guidelines and the knowledge composition of drinking different amounts of alcohol and the perceived social pressure surrounding alcohol use.	Cross-sectional study, online panel	N = 1932, 51.2% female, 17.8% 18–29, 30.1% 30–49, 52.1% 50+	General population 18+	Yes
Shahab et al. (2018) 68	2016	UK (England)	To estimate the prevalence of people’s beliefs concerning actual and mythical causes of cancer and their association with socio-demographic characteristics and health behaviour.	Cross-sectional study; computer-assisted face-to-face interviews by research company	N = 1327; 51.6% female M age = 43.7 (15.3)	General population 18+	Yes
Shanahan and Healy (2018) 63	2016	Ireland	To assess the level of awareness of oral cancer among non-consultant hospital doctors in Ireland.	Cross-sectional study, online survey	N = 221, 64.2% female, 71% 19–29 years old	Non-consultant hospital doctors working in general medical hospitals	No
Sinclair et al. (2019) 54	2015	UK	To explore the knowledge and attitudes towards alcohol as a risk factor for breast cancer, and potential challenges inherent in incorporating advice about alcohol health risks into breast clinics and screening appointments.	Part of a mixed methods study, survey at the clinic	Clinic attendees: N = 205, 100% female Clinic staff (health professionals): N = 33, 100% female	Women 18+ (general population and health professionals)	No
Systembolaget (2021) 75	2021	Sweden	To assess perceptions of alcohol and health among general population and health professionals.	Cross-sectional study, panel based	General public: N = 1000 Health professionals: N = 524	General public and health professionals	Yes
Thomsen et al. (2020) 55	2017	Denmark	To examine the awareness of alcohol as a risk factor for cancer in the Danish population.	Cross-sectional study, survey done through online panel	N = 3000, 50% female	General Population 18+	Yes
Varela-Centelles et al. (2021) 56	2015–2016	Spain	To investigate general awareness of oral cancer and knowledge about its risk factors, signs and symptoms.	Cross-sectional study, face to face survey on different locations	N = 5727, 52.3% females, 30.2% in the 45–64 age group	General population 18+	No
Volpe et al. (2022) 77	Not clear	Germany	Investigating awareness of risk factors for head and neck cancers among different groups of patients	Cross-sectional survey	N = 398 (42% female)	Patients	No
Wangmar et al. (2021) 69	2015–2016	Sweden	To investigate knowledge, values and preferences, and involvement among screening participants and non-participants in relation to colorectal cancer (CRC) and screening decision.	Cross-sectional study; web-based survey	N = 1481; 51.6% female Age range: 60–62 years	Adults invited to colorectal cancer screening aged 59-62	No
Warpenius, Markkula, Mäkelä (2018) 76	2016	Finland	Part of study describing results of the drinking habits survey in Finland	Cross-sectional survey	N = 2285 (48.7% female)	General population (15–79)	Yes

Study results

The main study results are presented in Table 2 and summarized in the paragraphs below by cancer type. The majority of the studies asked questions in a prompted manner, explicitly asking about awareness of the link between alcohol and cancer(s), six studies examined knowledge in unprompted manner (asking open questions about factors influencing cancer or diseases caused by alcohol), and six studies used both unprompted and prompted questions (starting with unprompted, and followed by prompted).

Table 2.

Study results 

Authors	Type of cancer	Prompted/ unprompted	Question framing	Results—cancer awareness
				General alcohol cancer link			Breast cancer	Colon cancer	Head and neck cancer a	Liver cancer	Oesophagus cancer
Agabio et al. (2021) 41	Breast cancer	Unprompted	To write down anything that might increase the risk of breast cancer. (% alcohol mentioned)				16.9% breast cancer screening attenders, 11.4% symptomatic breast screening attenders, 14.9% of non-screening group (no difference between groups)
Bates et al. (2018) 42	General	Unprompted	Which health conditions can result from drinking too much alcohol? (% cancer mentioned)	12.9%
		Prompted	Which health conditions can result from drinking too much alcohol? (% selecting cancer)	47.2%
Behrens, Lundgaard and Christensen (2022) 78	General	Unprompted	Which diseases do you think alcohol increases the risk of? (% alcohol mentioned)	21%
	General, breast, oesophagus, head and neck, liver, colorectal cancer	Prompted	Which of the diseases and conditions below do you think that alcohol increases the risk of? (% cancer selected)	47%			7%	22%	24%	40%	23%
Bocquier et al. (2017) 43	General	Prompted	Drinking alcohol, even in moderation, increases the risk of cancer. (% agree)	59%
Braekman and Fiers (2022) 82	General	Prompted	Scientists have proven that alcohol increases the risk of cancer. (% true)	44.6%
Bujalski and Stokwiszewski (2021) 81	General	Prompted	What do you think, which of the health disorders below can be associated with alcohol use? (% selected cancer)	67.3%
Christensen et al. (2019) 44	General, breast, oesophagus, head and neck, liver, colorectal cancer	Unprompted	Which diseases do you think alcohol increases the risk of? (% cancer mentioned)	T1: 22.2% T2: 27.0%
		Prompted	Which of the following (cancer) diseases and conditions alcohol increases the risk of? (% cancer selected)	T1: 44.8% T2: 49.7%			T1: 9.6% T2: 10.4%	T1 24.1% T2 26.8%	T1: 15.4% T2: 14.8%	T1: 39.5% T2: 42.9%	T1 26.1 T2 27.7
Davies et al (2022) 74	General	Prompted	Drinking less reduces your risk of 7 different sorts of cancer: is this information new to you? (% No)b		Observed data	Predicted probability
				Austria	33%	45%
				Belgium	38%	48%
				Czech Republic	36%	47%
				Denmark	44%	57%
				England	42%	50%
				Finland	52%	61%
				France	45%	56%
				Germany	36%	44%
				Hungary	46%	56%
				Italy	33%	52%
				Netherlands	39%	48%
				Poland	24%	35%
				Republic of Ireland	48%	54%
				Scotland	44%	54%
				Slovakia	41%	50%
				Spain	44%	50%
				Sweden	36%	46%
Di Giuseppe et al. (2020) 45	General	Prompted	Knowledge of drinking alcohol as risk factor for cancer. (% selected)	69.5%
Firincioglulari et al. (2022) 58	Mouth cancer	Prompted	Alcohol may cause mouth cancer. (% yes)						66% overall v65.4% of males 66.4% of females (mouth cancer)
Fisher et al. (2017) 46	Breast cancer	Prompted	Drinking too much alcohol may increase any woman’s risk/my risk of developing breast cancer. (% agree)				64.7% any woman’s risk 31.0% personal risk
Foucaud et al (2018) 70	General	Prompted	Factors liable to promote the onset of cancer (% definitely or probably)	84.8% Drinking more than three glasses of alcohol per day (men) (44.2% definitely + 40.6% probably) 77.9% Drinking more than two glasses of alcohol per day (women) (35.4% definitely + 42.4% probably)
Frola and Barrios (2017) 66	Oral cancer	Prompted	Knowledge of risk factors for oral cancer (% correct)						72.7 % (oral cancer)
Gerber et al. (2022) 83	Oral cancer	Prompted	Which of the following factors, in your opinion, may affect development of cancer in oral cavity? (% selected alcohol)						Total sample: 69.8% Poland: 61.5% Germany: 88.6% (oral cancer)
Hansen, Lundgaard and Christensen (2022) 79	General	Unprompted	Which diseases do you think alcohol increases the risk of? (% alcohol mentioned)	19%
	General, breast, oesophagus, head and neck, liver, colorectal cancer	Prompted	Which of the diseases and conditions below do you think that alcohol increases the risk of? (% cancer selected)	46%			8%	20%	21%	38%	19%
Kawecki et al. (2019) 47	Mouth cancer	Prompted	Drinking alcohol heavily as a risk factor for mouth cancer. (% identified)						58.8% (mouth cancer)
Kelly and Richmond (2018) 62	General	Prompted	Alcohol could cause cancer. (% agree)	59.6%
Koczkodaj et al. (2019) 48	Breast cancer	Prompted	Alcohol consumption as risk factor for the breast cancer. (% accurate)				26%
Košir et al. (2020) 85	General	Prompted	Awareness of alcohol as a risk factor for cancer. (% aware)	44 %
Krentowska et al (2018) 49	Head and neck cancer	Prompted	Alcohol as risk factor for head and neck cancer. (% selected)						43.4%
Leuci et al. (2022) 7 2	Oral cancer	Prompted	Do you consider abusive alcohol consumption as a risk factor for oral cancer? (% Yes)						98.5% (oral cancer)
Lotrean et al. (2021) 50	General	Prompted	Alcohol consumption could increase the risk of cancer. (% Agree totally/partially)	73.1 % agree (9.9% disagree 16.2% doesn’t know)
Luckman et al. (2017) 51	General link (not reported)/liver	Unprompted	Which lifestyle factors have an impact upon on each of the cancers you have learnt about? (% mentioning alcohol and liver cancer link)							> 90%
Martin et al. (2018) 65	General, breast, mouth, liver, pharyngeal, bowel, oesophageal, laryngeal cancer	Prompted	Alcohol-cancer awareness (‘greatly increases’/‘increases a little’/‘does not increase the risk’) (% increases risk (greatly + a little))	T1: 57.9% T2: 62.2% T3: 65.6%			T1: 33.0% T2: 44.3% T3: 44.7%	T1: 50.7% T2: 54.4% T3: 59.4%	Mouth cancer: T1: 50.4% T2: 55.1% T3: 56.5% Pharyngeal cancer: T1: 49.6% T2: 54.2% T3: 54.6% Laryngeal cancer: T1: 48.9% T2: 51.4% T3: 53.5%	T1: 84.9% T2: 74.7% T3: 79.1%	T1: 47.8% T2: 51.3% T3: 54.6%
Morere et al. (2018) 64	Breast cancer	Unprompted	What are the five main risk factors that increase the risk of breast cancer? (% alcohol mentioned)				3.8% of physicians 5.5% of laywomen
Morgernstern et al. (2021) 71	General	Prompted	Alcohol can cause cancer. (% Yes)	36.3% in control group not seeing cancer label 57.0% after seeing cancer label
Murariu et al. (2022) 73	Oral cancer	Prompted	Identifying risk factors for oral cancer (one of them being alcohol) (% alcohol selected)						73.1% overall 56.6% fourth year students 87.3% fifth year students 80.6% residents (oral cancer)
Nocini et al. (2020) 84	Oral cancer	Prompted	Alcohol consumption as a factor related to an increased risk of oral cancer. (% selected)						58.01% (oral cancer)
National Cancer Control Programme (NCCP) 52	General	Unprompted	What things do you think could increase a person’s chance of developing cancer? (% mentioned alcohol)	42%
	General	Prompted	For each of the following can you tell me which, if any, of these you think increase a person’s chance of developing cancer. (% yes to drinking alcohol) Drinking alcohol, even moderately, increases the risk of developing cancer. (% agree—strongly or moderately) Drinking alcohol can only cause cancer if you drink a large amount over a long period of time. (% agree—strongly or moderately)	73% 50% (11% strongly agree, 39% moderately agree) 45% (20% strongly agree, 25% somewhat agree)
O’Dwyer et al. (2021) 61	Breast cancer, bowel cancer	Prompted	Health conditions related to consuming more than the recommended number of standard alcoholic drinks in a week. (% selected)				21.2%	39.7%
Pérez-González et al. (2022) 59	Oral cancer	Prompted	Not specified						73% (oral cancer)
Petrova et al. (2021) 53	General	Prompted	How much influence (alcohol) has for a person to develop cancer? (1—has no influence to 10—lots of influence) % above 5 on influence scale	78.7% above 5 on 1–10 influence scale (M = 7.3)
Pinkas et al. (2022) 60	Head and neck cancer	Prompted	What are the risk factors for head and neck cancer? (% selected excessive alcohol consumption)						33.6%
Quatremère et al. (2022) 80	General	Prompted	In your opinion, does drinking alcohol present a risk of cancer? (% yes)	Not exposed to campaign: T0: 74.9 T1: 80.6 T2: 85.3 Exposed to campaign: T0: 79.0 T1: 86.5 T2: 86.0
Rupel et al. (2020) 67	Oral cancer	Prompted	Which are the possible risk factors for oral cancer? (% selected alcohol)						34.6% before lecture 92.6% after lecture (oral cancer)
Schouten et al. (2021) 57	Oral and pharyngeal cancer, oesophageal cancer, colon cancer, breast cancer	Prompted	Excessive alcohol consumption increases the risk of following conditions and diseases: (list of cancers). (% selected)				15.3%	25.8%	36.7% (mouth and throat cancer)		45.3%
Shahab et al. (2018) 68	General	Prompted	Any alcohol consumption as risk factor for cancer (% selected)	∼40%
Shanahan and Healy (2018) 63	Oral cancer	Unprompted	What would you consider as risk factors for oral cancer? % mention alcohol						63.3% (oral cancer)
Sinclair et al. (2019) 54	Breast cancer	Unprompted	Write down anything you think might increase the risk of breast cancer. (% alcohol mentioned)				19.5% of clinic attenders 48.5% of clinic staff
Systembolaget (2021) 75	General	Prompted	To what extent do you think that low and moderate/ high alcohol consumption increases the risk of suffering from certain forms of cancer? (% responded can increase)	Healthcare professionals: 63% high consumption General public 43% high consumption 14% low to moderate consumption
Thomsen et al. (2020) 55	General, cancers of the breast, oesophagus, head and neck, liver, colorectal	Unprompted	Which diseases do you think alcohol increases the risk of? (% cancer mentioned)	22.2%
		Prompted	Which of the following (cancer) diseases and conditions alcohol increases the risk of? (% cancer selected)	44.8%			9.6%	24.1%	15.4%	39.5%	26.1%
Varela-Centelles et al. (2021) 56	Oral cancer	Unprompted	What are risk factors for developing oral cancer? (% mention alcohol)						12.5% (oral cancer)
Volpe et al. (2022) 77	Oral cancer	Prompted	Knowledge of alcohol abuse as a risk factor. (question not clear)						40%
Wangmar et al. (2021) 69	Colorectal cancer	Prompted	What factor(s) do you feel are important for bowel cancer to develop? (% selected alcohol)					43.1%
Warpenius, Markkula, Mäkelä (2018) 76	General	Prompted	Alcohol consumption increases the risk of the following diseases or disorders: (% strongly agree with cancer)	37%

^aHead and neck cancers are cancers that occur around the head and neck and affect body parts such as lips, mouth, throat, sinuses, salivary glands, larynx and ear. Different authors measured different aspects: while some framed it as “head and neck cancer” in their questions, others framed it as oral, mouth, throat, or even more specifically referring to pharyngeal (=throat) and laryngeal (=voice box) cancer.

^bPredicted probability estimates are aggregates across equally weighted age, sex and AUDIT score categories, whereas observed data may be skewed to particular demographic group.

Awareness of the general alcohol cancer link

Unprompted

Among the 24 papers that studied the awareness of the general alcohol-cancer link, 6 had unprompted queries, all with rather low percentages. In England, 13% of the population was aware of the alcohol cancer link unprompted in 2015.⁴² In the Danish general population sample, the unprompted awareness was 22.2% before the campaign⁵⁵ and 27.0% after the campaign⁴⁴ (data from 2017/2018), 21% in the most recent dataset from 2020,⁷⁸ and 19% among young people in 2021.⁷⁹ In the Irish survey from 2022, 42% participants mentioned alcohol when asked what increases cancer risk.⁸⁴

Prompted

Prompted questions led to higher awareness rates, but with large country differences. In England in 2015, 47% of the population were aware of the alcohol cancer link⁴² (with another study from the same period estimating 40%⁶⁸), as was 65.6% of the North East England population after the awareness campaign.⁶⁵ In the EU, countries with relatively high awareness are France (85% according to 2019 data among drinkers),⁸⁰ Spain (78.7% rated alcohol as a cancer risk higher than 5 on 1–10 scale⁵³), Ireland (73% mentioned alcohol as risk factor for cancer in 2022, while 50% agreed that even moderate alcohol consumption can increase cancer risk⁸⁴) and Poland (67% associated cancer with alcohol use).⁸¹ Recent data (2020–22) point to lower awareness in Sweden (43% considered high alcohol consumption increases cancer risk, whereas 14% considered low-to-moderate consumption doing so⁷⁵), Belgium (45%)⁸² and Denmark (47%).⁷⁸ In Finland in 2016, 37% participants strongly agreed that alcohol increases risk of cancer.⁷⁶ In a large multi-country study done as part of Global Drug Survey in 2017/2018⁷⁴, between 24% and 52% (observed data), and 35–61% (data weighed for demographic variables) of people who use drugs considered that information about drinking less reducing their risk of cancer is not new to them.

Among specific populations, 59.6% of the Irish cancer survivors thought alcohol could cause cancer.⁶² The awareness of the general alcohol-cancer link was somewhat higher among younger people (although with exception of the Danish study, this data comes from convenience samples): 46% among Danish 15–25 year-olds,⁷⁹ 44% among the Slovenian elementary school students,⁸⁵ 69.5% among the Italian high school students⁴⁵ and 73.1% among the Romanian university students.⁵⁰ In health warning labelling study, 57% secondary school students in Germany who were exposed to cancer message as part of the study were aware of the link between alcohol and cancer afterwards, compared to 36.3% of the non-exposed students.⁷¹ Among a sample of Swedish healthcare professionals, 63% considered high alcohol consumption increases cancer risk.⁷⁵

Awareness of the links between alcohol and specific cancers

Breast cancer

The awareness of the link between alcohol and breast cancer has mainly been studied among women and among general population. Among women, awareness of the link between alcohol and breast cancer was found to be between 5% and 25%, with the exception of one British sample in England. In the Italian female sample, between 11% and 17% listed alcohol as a risk factor for cancer unprompted,⁴¹ in the English sample, 19.5% women did so,⁵⁴ and in the French sample, 5.5%.⁶⁴ Furthermore, 26% of Polish women identified alcohol as a risk factor for breast cancer when prompted,⁴⁸ and in the English sample 64.7% women said that alcohol can increase any woman’s risk, but only 31.0% thought it could increase their personal risk.⁴⁶

Awareness of breast cancer link among the general population was also rather low: 9.6% of Danish population were aware of the link before the campaign⁵⁵ and 10.4% after the campaign,⁴⁴ with most recent data from 2020 pointing to decrease of that percentage to 7%⁷⁸; as did 15.3% of the Dutch,⁵⁷ 21.2% of the Irish⁶¹ and 33% of the English populations⁶⁵—in the latter case, this percentage increased to over 44% after the awareness campaign. Among the other populations, 48.5% of English staff of the breast unit⁵⁴ and 3.8% of French female physicians⁶⁴ were aware of the link between alcohol and breast cancer (both unprompted), as were 8% of Danish 15–25 year-olds.⁷⁹

Head and neck cancers

The awareness of the link between alcohol and head and neck cancers (broad category comprising also questions referring to mouth, oral, throat and pharynx cancers) ranged between 15% and 40% in the representative general population samples (with exception of the British samples). In Denmark, it was 15.4% in 2017, 14.8% in 2018^44,55 and 24% in 2020⁷⁸; in Spain, it was 12.5% (unprompted),⁵⁶ in Poland 33.6%⁶⁰ and in the Netherlands 36.7%.⁵⁷ Among Scottish adults, almost 60% were aware of the link between alcohol and mouth cancer,⁴⁷ and in England, around 50% were aware of the mouth, pharynx and larynx cancer link before the campaign, which increased for few percentage points after the awareness campaign.⁶⁵ The awareness also appeared to be slightly higher in other non-representative samples: 58.1% of the Italian general population,⁵² 66% of the Cypriot dental clinic attendees,⁵⁸ 88.6% and 40% of German oral cancer patients,^77,83 61.5% of Polish oral cancer patients⁸³ and 43% of the Polish young adults (18–35).⁴⁹ The awareness was found to be higher also among medical students and professions—63% among the Irish non-consultant hospital doctors,⁶³ 73% among Spanish medical and dentistry students,^59,66 73.1% among Romanian dental students and dentistry residents,⁷³ and 98.5% among Italian dental hygienists.⁷² Finally, the awareness of Italian middle school students (12–14 years) was 34.6% (before receiving educational intervention),⁶⁷ and 21% among Danish 15–25 year-olds.⁷⁹

Colon cancer

Awareness of the colon cancer and alcohol link ranged between 25% and 50% in the general populations, except after the mass media awareness campaign in the UK: 22% in Denmark at the most recent measurement,⁷⁸ 25.8% in the Netherlands,⁵⁷ 39.7% in Ireland,⁶¹ 43% in Sweden⁶⁹ and 50.7% in the UK.⁶⁵ Among Danish 15–25 year-olds, 20% were aware of the link.⁷⁹

Oesophagus cancer

The awareness of the link between alcohol and oesophagus cancer also ranged between 25% and 50% in the general population samples: 26.1% in Denmark at its highest,⁵⁵ 45.3% in Netherlands⁵⁷ and 47.8% in the UK pre-campaign (with increase to 54.6% after the campaign).⁶⁵

Liver cancer

Liver cancer and alcohol link was correctly identified by 40% of Danish respondents at its highest,⁷⁸ whereas in the English general population sample the awareness was rather high (almost 85%),⁶⁵ as was in the sample of English university medical students (>90%).⁵¹

Discussion

This review summarizes the existing evidence regarding public awareness of alcohol-cancer link in the EU and UK. Forty-five studies covering 19 countries were included, including 17 studies in ten countries examining nationally representative samples. Next to identifying general population’s awareness, studies focused on women, health professionals, patients and young people. Unprompted general alcohol-cancer link awareness, as well as awareness of the link between alcohol and specific cancers was under 50% in every sample. Awareness of the link to liver and head and neck cancer appeared to be higher compared to other cancers, for the latter especially due to studies of current or future professions for whom that might be relevant professional knowledge (e.g. medical and dentistry students). Despite breast and colon cancer representing 15% and 29% of alcohol-related cancers in EU, respectively,⁶ awareness of their link with alcohol appears low. The low breast cancer awareness among women, with only slight increase from 1% to 7% in the early 2000s,²³ is especially concerning, as is low awareness among some health professionals.

The findings highlight issues in how awareness is measured. They can be influenced by the way the question is posed (in unprompted or prompted manner, or asking about any, low-to-moderate or excessive alcohol consumption); and the answer options (using Likert scale asking about agreement, or asking in Yes/No format). Despite not being able to pinpoint the accuracy of the single datapoints, looking at all the results in unison shows certain trends—lower unprompted awareness, which means alcohol and cancer relationship is not salient in people’s minds, and low awareness of specific cancers such as breast and colon cancer. Higher prompted awareness of the general alcohol-cancer link in some countries might demonstrate actual improvement in knowledge but can potentially also represent an overestimation, as many people might answer based on an overall notion that nowadays ‘everything’ can cause cancer. For example, in the Dutch study included in the review,⁵⁷ 15.4% of respondents also associated alcohol with increased skin cancer risk, and in the 2009 Eurobaromater,¹⁴ 42% agreed that alcohol increases asthma risk (for both there is lack of evidence). This issue can be addressed with communication of tailored and specific information related to alcohol-cancer risk and situating the burden of disease due to alcohol-related cancers in relation to other causes.

There might be some parallels between the tobacco and alcohol field in the context of establishing the substance link with cancer and communicating this knowledge to the public. For example, in the USA, the evidence on link between tobacco and lung cancer was already established in mid-1950s,²⁴ but public awareness lagged for few decades, also due to concentrated efforts by the tobacco producers to downplay the link by casting doubt on the evidence and emphasizing complex cancer aetiology. Nowadays, this link is well known due to comprehensive policy response combined with educational measures.^24,25 Alcohol was declared as carcinogenic by IARC already in 1988,¹ and evidence was emerging in the decades beforehand (e.g. Refs^26–28). The results of our review show that almost four decades later, this information is still not widely known. Analysis of alcohol producers-developed content identified their influence in creating the narrative surrounding alcohol-cancer link through denying, omitting or misrepresenting the risk,²⁹ with most misrepresentation focused on the cancers with the lowest awareness: breast and colon.

Limitations

There are limitations both on the review and study level. One, the included studies have not been systematically appraised for quality, and there is likely a broad range of quality of methodology among the included studies—from nationally representative general population studies to small convenience samples—implying that some findings are likely to be more relevant and valid than others. For this reason, we considered the nationally representative samples as a proxy for higher quality methodology, and gave more weight to those studies when summarizing the findings. Two, as previously mentioned, the responses to the questions are likely dependent on the question wording and are thus not always directly comparable. While we present the question framing, it was beyond the scope of this review to investigate exact impact of the question wording on the response.

On studies level, potential answering biases (especially in the prompted questions with Likert scale answers) should be considered—implying that the results on awareness of the alcohol cancer link obtained through prompted questions might be overestimated. Finally, among the found studies, the year of data collection was sometimes 10+ years ago, meaning not all results reflect the current levels of awareness. Studies (especially nationally representative studies) from Central and Eastern European countries were also lacking.

Implications for practice and research

The finding that a large number of Europeans is likely still unaware of alcohol being a cancer risk factor points to the need for better informed citizens. Raising awareness may be done by means of mass media campaigns, which might have a small impact.^30,31 Another way of raising awareness can be providing consumers with this information on the point of purchase and consumption—specifically through health warning labels at the point of sale and on the alcohol products itself. In the EU, Ireland is the only country with legislation to include cancer warning on the labels of alcoholic beverages, with legislation to be enforced from 2026,³² and the European Commission indicated potential plans to propose health warnings as part of the Europe Beating Cancer Plan.³³ This document presents a crucial opportunity to take a bold step towards providing relevant information to consumers in the EU. In Canada, cancer labels in combination with low-risk drinking guidelines and standard drink information have been shown to increase consumers knowledge (as well the associated support for alcohol policies¹²) self-reported alcohol consumption³⁴ and decrease alcohol purchases,³⁵ despite the industry interference which shortened the length of this real-world intervention.³⁶ The information-based ‘why-to-reduce’ messages in combination with action-based ‘how-to-reduce’ messages can thus lead to reconsideration of alcohol intake among people using alcohol.³⁷

Another major implication is the need for increased monitoring of the Europeans’ awareness, especially among the general population. France is setting a good example with consistent measurement,³⁸ and large national institutions in Belgium,⁸² Ireland,⁶¹ Denmark,^44,55,78 Finland,⁷⁶ Netherlands⁵⁷ and Sweden⁷⁵ have recently also started surveying the population on awareness of the alcohol-cancer link. Questions used in the Danish studies,^44,55,78 which first examine unprompted awareness of the alcohol cancer link, followed by prompted awareness for the specific cancers, could be used in future studies. On the EU level, the future Eurobarometer studies could include such questions to gain a better understanding of knowledge and cover a broad demographic. However, further research is necessary into how people are interacting with receiving such message, including within the context of continuous media reports on new substances causing cancer. Australian research on introducing cancer labels shows that it is likely the legitimacy of the cancer messages will be challenged by the consumers themselves,³⁹ and low initial awareness might lead to people perceiving provision of such information as irrelevant, even in healthcare settings.⁴⁰ This also points to the importance of situating the efforts to increase the cancer awareness within the implementation of wider range of effective measures to reduce alcohol-related harm—such as those proposed in the WHO SAFER initiative (availability and advertising restrictions, pricing policies, drink driving countermeasures and screening and brief interventions).⁷

Conclusion

In the EU general population representative samples, less than half of the respondents correctly identified link between alcohol and specific cancers. This was the case especially for the cancers with highest disease burden, such as colon and breast cancers. Young people and specialized health professions tended to have higher awareness. More efforts are necessary to inform the European population about the link between alcohol and (specific) cancers.

Supplementary data

Supplementary data are available at EURPUB online.

Funding

The research leading to these results or outcomes has received funding from the EU4Health under Contribution Agreement no. SANTE/2022/SI2.883729 (Addressing alcohol harm—capacity building, raising awareness and implementation of best practices in the Union). Its contents are the sole responsibility of authors and do not necessarily reflect the views of the European Union.

Conflict of interest

None declared. C.F.-B., M.N. and G.G. are staff members of World Health Organization; D.K. and A.T. are WHO consultants. The authors alone are responsible for the views expressed here and these do not necessarily represent the decisions or the stated policy of WHO.

Key points:

• In the EU, general population’s awareness of link between alcohol and cancer is still often lacking, although it is higher for cancer in general than for specific cancers, and varies by country and question wording.

• Awareness of link between alcohol and specific cancers (e.g. breast cancer) is especially low.

• Cancer awareness was found to be higher in convenience samples of young people and health professionals.

• More efforts are necessary to inform the European population about the relationship between alcohol and cancer.

Data availability

The data used in this scoping review were obtained from publicly available sources. No primary data collection was conducted for this study. All relevant publications and reports included in the review are included in the reference list, and all data extracted for analysis during this study are included in the article and its Supplementary files.