Jessai Flores

In 2020, the American Cancer Society highlighted alcohol as the third leading preventable cause of cancer. According to U.S. Surgeon General Vivek Murthy MED ’03 SOM ’03, more than half of Americans aren’t aware of the cancer risk that alcohol presents to society, drawing concern given the drink’s protagonism in celebrations, social traditions and marketing campaigns. 

That’s why, this month, in one of his final policy recommendations, Murthy has called attention to the cancer risks associated with alcohol and urged Americans to reduce their consumption. He also proposed adding cancer risk warnings to alcoholic beverage labels as one strategy to address this issue. And while Yale experts agree with the recommendation, some believe the relationship between alcohol and cancer is more complex than the surgeon general suggests.

“I don’t disagree with putting the warning label on alcohol,” said Vasilis Vasiliou, co-chair of the T23 Translational Alcohol Research program and professor of environmental health sciences, “However, I want people to be informed and make educated decisions regarding this. If you are a smoker and you drink a lot [of] alcohol, you are at a higher risk, that’s for sure.”

The research behind the federal recommendation

Alcohol consumption has been linked with various negative side effects. According to Xi Chen, associate professor of health policy at the School of Public Health, alcohol has been linked with dehydration, nausea, impaired judgment and other conditions.

According to Vasiliou, alcohol can cause cancer in various ways. It can damage DNA, alter the normal levels of estrogen — increasing the risk of breast cancer — and potentially cause a greater absorption of other carcinogens such as tobacco smoke.

“During the alcohol’s metabolism, you have the generation of reactive oxygen species,” Vasiliou told the News, “If you don’t have antioxidants from a very well-balanced diet, you can increase your oxidative stress, raising the risk for cancer.”

Research has shown that alcohol increases the risk of cancer for at least seven sites, ranging from the liver to the mouth to the throat to the breast in women. If a man consumes seven drinks every week, his risk of developing alcohol-related cancer increases from 10 percent to 11.4 percent; for women, the increase is more drastic, from 16.5 percent to 19 percent. 

Though the increase in cancer risk seems marginal, associate professor of psychiatry Lisa Fucito believes at the population level, they are huge. In the United States, alcohol use contributes to nearly 100,000 cancer cases and about 20,000 cancer deaths annually. 

The recommendations for action

More than 50 percent of Americans don’t know that alcohol consumption increases cancer risk. And in a state such as Connecticut — ranking in the top 20 states with the most alcoholics — spreading the knowledge about the cancer risk of alcohol is of even more importance. According to Chen, the lack of sufficient public health messaging about alcohol’s cancer risk has led to the information disparity.

“Though there have been some beliefs that alcohol has some benefits, the Surgeon General wants to correct that message,” Chen told the News. “There’s no benefit to drinking. Since it’s not a necessary consumption, if you can avoid drinking on some occasions, try to do that.”

Younger generations are drinking alcohol at lower rates than older generations. Though a cause to be hopeful, Marcella Nunez-Smith, director of community engagement and health equity at the Yale Cancer Center, believes that more work needs to be done to change the narrative around alcohol at a mass level. In her view, the Surgeon General’s recommendations can do just that. 

Warning labels

One way to educate the public about the cancer risks of alcohol is through updating the health warning labels on alcoholic drinks. According to Nunez-Smith, the last update to these labels was in 1988. Since then, the labels have only briefly mentioned potential health risks and addressed birth defects related to pregnancy and impaired driving. 

“Warning labels have been a tremendous success globally for communicating the risks of tobacco use at the population level and changing population risk perceptions about tobacco use,” Fucito wrote to the News. “Applying labels directly to products is important because they provide a continuous reminder and public health messages communicated via other ways may be missed.”

However, according to Nunez-Smith, some New Haveners aren’t as comfortable with trusting health information from outside sources. To work around this, Nunez-Smith believes that community leaders can partner with public health professionals and raise awareness about the link between alcohol and cancer effectively, potentially through workshops or town hall meetings.

Fucito also suggested that healthcare professionals need to learn how to interact with patients about the cancer risk of alcohol. This can mean doctors and nurses learning to assess alcohol use, providing alcohol treatment resources and connecting patients with effective interventions. 

“The rule is, not just for this advisory, but for everything in public health, is that we provide people with information to make informed decisions,” Nunez-Smith said, “The information must be high quality, and that they receive it from trustworthy sources. But after that people will be armed with the information to make their individual choice.”

Complexities

However, the surgeon general’s recommendation has various nuances that need to be considered. 

According to Vasiliou, though there is a consensus that more alcohol leads to higher cancer risk, the precise amount of alcohol that elicits its various health repercussions — including cancer — is not known. 

Additionally, Vasiliou pointed out that most of the findings the surgeon general concluded are based on questionnaires given to cancer patients asking them about their alcohol behavior. This leads to bias and a lack of evidence-based conclusions. He believes more clinical evidence must be collected, including blood measurements. 

“We have a lot of gaps in our knowledge that need to be filled with further research,” Vasiliou told the News. “We need our epidemiology to be mostly based on clinical biomarkers showing that alcohol is the driving force of cancer, not just a contribution. We also need mechanistic studies, using human models to show the direct relationship between cancer and alcohol.”

According to Nunez-Smith, though reducing alcohol intake or removing alcohol from one’s diet will reduce the risk of cancer, it won’t completely remove it. Every individual has their own unique genetic and social factors that make it easier or harder for them to get cancer. Though at the population level, it is the consensus that drinking less alcohol will significantly reduce the risk for cancer, the individual risk varies.

“The issue is, at the individual level, people may have some healthier behavior to offset the harm generated by consuming alcohol,” Chen said, “Those who exercise can offset some of the risks that alcohol provides, but what we observe is the net impact.” 

According to Chen, it’ll also be difficult to turn the surgeon general’s recommendations into law. A majority of Congress will have to agree with the recommendation. With the large lobbying efforts of the alcohol industry in Congress and Health and Human Services, it’ll be difficult to change the opinions of many. 

Additionally, there are various other risk factors for developing cancer, such as obesity, and it’s important to highlight these are preventable causes of cancer risk. According to Chen, having a holistic approach when raising awareness about cancer risk is key to spreading the correct information. 

Vasliliou hopes that talking about cancer will serve as a conversation starter for cancer education, making individuals more informed about cancer risk in general. According to him, alcohol use disorder is a major problem in society and can wreak havoc on the individual body. Though the cancer risk of alcohol may need more evidence-based clarification, he encourages moderate drinking of alcohol due to its other negative effects.

This spring, the School of Public Health is hosting the 5th International Conference on Alcohol and Cancer.