Coming to terms with the alcohol-cancer link: A work in progress

Abstract

Although substantial evidence links even moderate levels of alcohol consumption to breast, colorectal, and five other cancers, awareness in the US population of this evidence is suboptimal. That lack of awareness—complemented by industry resistance to policy change—has hindered efforts to address alcohol use in cancer prevention. The article by Hawk et al. in this issue reports that 86% of surveyed NCI-Designated Cancer Centers believe they have an obligation to educate the public about the cancer harms associated with alcohol, a promising finding given that people trust clinicians more than other sources of health information. Nevertheless, Hawk et al. also find that nearly half of these Cancer Centers do not implement policies that de-emphasize alcohol use at sponsored events. Moreover, about half questioned the definitiveness of the current literature, although many indicated that knowledge of approaches taken at peer cancer centers could persuade them otherwise. The findings present some hope that progress is feasible, but significant barriers remain. We discuss the meaning of these findings along with parallels to the complex history of tobacco control.

It takes time for the conclusions of health research to enter public consciousness, influence policy, and alter population-level behavior. One needs to look no further than tobacco, the leading preventable cause of disease and death, including multiple cancers.¹ The 1964 US Surgeon General’s Report (SGR) on Smoking and Health was a watershed moment in the history of tobacco control, yet several barriers delayed the demonstrable public health impact we now enjoy. Public spaces such as airlines and restaurants did not become smokefree until the 1980s and 1990s, and the US was unable to able to mount a Center for Tobacco Products within the Food and Drug Administration (FDA CTP) until 2009. Tobacco control still faces challenges, given the persistent efforts of an industry highly motivated to sustain profits to the detriment of public health. Indeed, the FDA CTP has aimed since their founding to place graphic warning labels on cigarette packs—a practice adopted by many countries for years with clear benefit²—yet legal setbacks have continued to prevent adoption in the US. Fortunately, despite these barriers, most of the US population is well aware that combustible tobacco products are harmful and use has steadily plummeted since the 1964 SGR.

The challenges and successes faced in tobacco control offer context for burgeoning interest in tackling alcohol as a strategy for cancer prevention. The causal effect of alcohol on cancer risk has been acknowledged for over 40 years; the International Agency for Research on Cancer (IARC) identified ethanol as a carcinogen in 1988. Multiple epidemiological studies and reviews have since provided strong evidence that alcohol consumption causes at least seven cancers, including female breast and colon—two of the highest prevalence cancers.¹ Yet at least half (or more) of the US population is unaware that this is the case.³ How can that be?

The answer is, of course, multidimensional. Like tobacco, alcohol is an enormously profitable commodity, with a sprawling industry promoting its distribution and consumption. Efforts to publicize the hazards associated with alcohol use are thus met with resistance from a commercial sector with far greater resources than any public health entity. Added to that dynamic is the so-called “French paradox” that emerged from the legendary 1991 60 Minutes episode, which lauded the cardiovascular benefits of red wine. Although some of the ostensible benefits have since been attributed to methodological shortcomings, such as the inclusion of unhealthy non-drinkers as a comparator, the “heart health” story has had plenty of time to establish a stable residence in the public consciousness. Many skeptics (along with the beverage industry) point to the hedonic and social benefits of alcohol, making it much more difficult to come to terms with its potential harms. The US also has battle scars from the Prohibition Era, making efforts to rein in alcohol use even more challenging.

The tobacco story offers optimism that progress in the alcohol space is feasible. But how should the problem be tackled, and who is best positioned to do so? Strategies are needed at every level—from interpersonal exchanges (e.g., incorporating discussions into clinical interactions) to population-level approaches (e.g., policies that increase alcohol taxes and reduce access). There are indications that the time is right for reorientation: Gallup data show that alcohol purchases and use are down (despite increases during the COVID-19 pandemic), mocktails and “sober curious” events are more than a fad, and adolescents and young adults are slowly moving away from the use of some addictive substances.⁴ There is also strong support—across multiple subpopulations in the US—for requiring warnings about cancer on alcohol containers.⁵ In short, receptivity to change may be as high as it has been since the end of Prohibition.

What institutions might be best positioned to boost awareness and promote population-level change? Government organizations do play an important role; for example, the US Alcohol and Tobacco Tax and Trade Bureau has long been responsible for warning labels on alcoholic beverages. The barriers to changing these labels, however, are not insignificant. The US Office of the Surgeon General took a monumental step in January 2025 to release an Advisory on the carcinogenic effects of alcohol, one that advocated for such changes in labeling. However, the long-term impact of this Advisory remains to be seen.

It seems vital here to consider the sources that people trust most when engaging with health information and making health-related decisions. That consideration turns out to be no contest. By a large margin, people trust their healthcare providers more than other sources, including government organizations and online materials.⁶ Moreover, at least one analysis shows that patients whose providers discuss the effects of alcohol on cancer risk express more awareness of this association.⁷

In that context, it is intriguing to consider the article by Hawk, Martch, Si, and Shete in this issue.⁸ The authors report the results of an innovative and timely survey of NCI-Designated Cancer Centers about their approach to alcohol and cancer. These Cancer Centers serve as a major leader in the cancer control space, working both to treat their patients and to engage with their catchment areas to reduce cancer morbidity and mortality. They have demonstrated the ability to work together productively; for example, NCI-Designated Cancer Centers have banded together more than once to release joint statements about the importance of HPV vaccination in preventing cervical cancer.⁹ A group of 52 cancer centers received administrative supplements as part of the NCI-led Cancer Center Cessation Initiative, leading to nationwide improvements in how tobacco use is tracked and treated in NCI-Designated Cancer Centers, and, more recently, the larger network of community cancer centers.

There has yet to be a coordinated effort by cancer centers to address alcohol and cancer risk, but it is clear from Hawk et al.’s analysis that many individual cancer centers already have this topic on their radar. The authors found that 86% of respondents—which included Directors, Associate Directors, Presidents, and CEOs—believed it was part of their job to educate the public about the effects of alcohol on cancer (with a reasonable 61% response rate). More than half (56%) explicitly acknowledged an organizational responsibility to mitigate the burden of alcohol-related cancers, and about half (52%) indicated that their organization had implemented policies about the use of alcohol at sanctioned events, suggesting some inclination to address alcohol as a risk factor across multiple levels.

Although these findings offer promise, they were offset by several others that suggest a “work in progress,” resembling the early days of tobacco control. The 61% who responded are likely more inclined to address this topic than the nontrivial 39% who did not. Moreover, although half of the responding Cancer Centers did have policies in place, half did not. The latter finding could be partly explained by the fact that nearly half of respondents (45%) did not consider the alcohol-cancer matter sufficiently settled to warrant organizational change—with 23% still endorsing health benefits of alcohol (and an additional 20% ambivalent or unsure). It is reasonable to question the self-reported nature of epidemiological data on alcohol use, and there is also little to no evidence for many rare cancers. Nevertheless, Mendelian and longitudinal studies—tracking cancer incidence for many years after changes in alcohol use^e.g.,10—cannot be easily explained away.

Skepticism is only one barrier; another is that many respondents indicated a lack of knowledge about (and a corresponding interest in) the approaches being taken at other cancer centers. A substantial proportion (63%) of respondents who were unconvinced by the current literature reported that data on peer institutions might persuade them otherwise. Importantly, the publication of the Hawk et al. article is itself a major step in providing a window into these peer institutional norms. As we know from the emergence of smokefree policies, the development and establishment of norms can take time. As Cancer Centers begin to take stronger actions and share those actions with their peers, progress will likely accelerate.

It should be noted that this survey was conducted prior to the aforementioned release of the Surgeon General’s Advisory and other related reports, as well as the subsequent flurry of media coverage. Awareness of the alcohol-cancer link has been relatively steady over many years, with levels of awareness approaching 50%. Although still a long way from current public awareness of the harms of tobacco, a tipping point may be on the horizon, leading to a hastening of efforts to address alcohol head-on as a cancer risk factor. Policymakers, scientists, educators, public health professionals, and others share the responsibility of not just increasing awareness but also conveying accurate information that will help the public make informed decisions. If 86% of cancer centers truly believe they possess this responsibility as well, they might be particularly helpful in leading the charge toward a more integrated national approach. Hawk et al. have shown us that progress is modest, but given the tobacco model, it is imaginable.