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Angie Garrett via Wikimedia Commons

A coalition of consumer and public health groups is pushing for a government-required warning that alcohol consumption causes cancer on labels of liquor bottles and other alcoholic beverage containers.

Currently, federal law requires a “health statement” on the label of all alcoholic beverage containers warning that alcohol consumption “may cause health problems” — specifically, that it impairs the ability to drive or operate machinery and, during pregnancy, risks birth defects. That warning has not changed since 1988, when Congress enacted the law mandating the health statement. The law also directs the Alcohol and Tobacco Tax and Trade Bureau (“TTB”, part of the Department of the Treasury), in consultation with the Surgeon General, to “promptly” notify Congress of the need to update the health statement if “available scientific information would justify a change” and to make “specific recommendations” TTB determines “to be appropriate and in the public interest”.

According to the American Public Health Association, the American Society for Clinical Oncology, the Consumer Federation of America, a coalition of breast cancer organizations, and similarly-minded groups, the “available scientific information, accrued over more than three decades, shows that alcohol causes cancer”, yet the TTB has taken no action. Thus, the organizations (eight in all) filed a Citizen Petition (per federal regulations) with the Department of the Treasury requesting that the TTB report this scientific consensus to Congress and recommend that Congress amend the current health disclosure to state:

WARNING: According to the Surgeon General, consumption of alcoholic beverages can cause cancer, including breast and colon cancer.

The petition asks that this warning be put in rotation with the two existing health statements, citing increased consumer awareness of information that is new or different.

In support, the petition summarizes the evidence on the association between alcohol consumption and cancer, the public’s lack of awareness of that association (we’ll look at industry efforts to keep it that way in a moment), and the drinking habits of Americans.

According to the petition, quoting the National Cancer Institute, “there is a strong scientific consensus that alcohol drinking can cause several types of cancer”. American Cancer Society (ACS) researchers estimate that, in 2014, alcohol consumption was associated with an estimated 6.4% of all cancer cases in women (50,110 cases) and 4.8% of all cancers in men (37,410 cases). The largest burden “by far” was for female breast cancer (39,060 cases), per the ACS, which says that in the U.S.,

alcohol consumption represents the third largest contributor to cancer in women (behind smoking and obesity) and the fourth largest contributor to cancer in men (behind smoking, obesity, and UV radiation).

The World Health Organization’s International Agency for Research on Cancer (IARC), in 2012, considered the data on alcohol’s contribution to cancer and concluded that there is sufficient evidence in humans for the carcinogenicity of alcohol consumption causing cancers of the oral cavity, pharynx, larynx, esophagus, colorectum, liver, and female breast. The IARC also concluded that even low levels of consumption (“up to 1 drink/day”) increases the risks of some cancers. The 2016 report, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, agrees, reporting that “[e]ven one drink per day may increase the risk of breast cancer” and “light” drinking (up to one drink per day) is associated with an increased risk of cancer of the oral cavity, pharynx, and esophagus.

To top this off, the petition references research from several other organizations.

  • World Cancer Research Fund and American Institute for Cancer Research: “strong evidence that consuming alcoholic drinks increases the risk of cancers” of the mouth, pharynx, larynx, esophagus, breast, stomach, liver, and colorectum.
  • American Society of Clinical Oncology: “the relationship between drinking alcohol and cancer risk has been evaluated extensively in epidemiologic case-control and cohort studies” and “[e]ven the modest use of alcohol may increase cancer risk.”
  • American Cancer Society: “it is best not to drink alcohol” but those who do choose to drink should limit their consumption to no more than one drink per day for women and two drinks per day for men.
  • National Toxicology Program of the U.S. Department of Health and Human Services: alcohol is a known human carcinogen, a conclusion reached in 2000.
  • 2020 Dietary Guidelines Advisory Committee: Do not drink alcohol “because you think it will make you healthier”; recommends limits of one drink per day for both men and women. [Somewhat controversially, the Trump Administration rejected this recommendation, along with the Committee’s recommendation for further limiting sugar consumption.]

In addition to taking on the notion that moderate drinking does not have adverse health effects, the petition rejected the claim that there is an association between moderate drinking and health benefits, quoting the CDC:

Although past studies have indicated that moderate alcohol consumption has protective human benefits (e.g., reducing risk of heart disease), recent studies show this may not be true. While some studies have found improved health outcomes among moderate drinkers, it’s impossible to conclude whether these improved outcomes are due to moderate alcohol consumption or other differences in behaviors or genetics between people who drink moderately and people who don’t.

Despite this sobering news, according to the petition, while the evidence is limited, it indicates that few consumers are aware of the link between alcohol and cancer. A 2019 American Institute for Cancer Research survey showed that just 45% of adults identify alcohol as a cancer risk. A National Cancer Institute survey, also in 2019, found 32% of respondents identified cancer as a health condition that can result from alcohol consumption.

(Personally, based solely my own experience in over a decade of blogging at SBM, this is a refreshingly high level of knowledge about any health subject, considering the plethora of misinformation and lack of critical thinking that abounds in healthcare. But that’s just me.)

Given the fact that alcohol consumption is a totally preventable risk factor for cancer, based on our current drinking habits, the petition finds much room for improvement in Americans’ health, citing data showing:

  • More than half of the population aged 12 (!) or older reports drinking alcohol within the last 30 days.
  • Excessive drinking, associated with the greatest cancer risk, increased over the last decade.
  • In 2015, 22% of men and 10% of women reported consuming more than 7 drinks per week; 11% of men and 5% of women reported more than 14 drinks per week. (Not to minimize the gravity of these statistics, and maybe I’m just in with the wrong crowd, but I would expect these percentages to be higher.)
  • In 2018, 26.45% of people aged 18 or older reported they engaged in “binge drinking” (5 or more drinks for men, 4 or more for women, on one occasion), and close to 7% engaged in binge drinking on five or more days per month, considered “heavy drinking”.

Big Booze fights back

According to the director of food policy at the Consumer Federation of America, the petition was inspired in part by a Canadian study using an identical warning. That study both produced useful data on increased consumer awareness after warnings appeared and previewed for the petitioners how the alcohol industry will fight such warnings tooth and nail.

In 2017, Canadian researchers planned to place three different types of information labels on tens of thousands of containers of booze sold in the city of Whitehorse, Yukon. One warned of cancer risks; two others had information related to Canada’s low-risk drinking guidelines. The messages were to have been evaluated through analysis of alcohol sales data and surveys of liquor store customers in Whitehorse and in Yellowknife, Northwest Territories, which was used as a control. Unfortunately, and predictably, the alcohol industry successfully intervened and the labelling research was halted by the government a few months in. One industry strategy was to claim this research was unlawful, a claim experts later termed “groundless”, part of a game plan the industry has employed successfully in other jurisdictions.

Unfortunately for the industry, even the truncated study provided useful data: Shoppers in Whitehorse were significantly more likely to know about alcohol’s cancer risk than control groups and total alcohol sales decreased by more than 6%. The industry’s attempts to sabotage the research also produced something of a Streisand effect, garnering unflattering Canadian and international media attention.

In addition to making dubious legal claims, the alcohol industry, in fact, has a long history of misleading the public regarding connections between health and drinking, according to a 2017 Mother Jones exposé. Seemingly taking a page from the tobacco playbook, the industry has emphasized the (debunked) health benefits of alcohol (especially wine), sponsored popular sporting events like the Super Bowl and NASCAR, funded studies casting alcohol in a favorable light and doubt on unfavorable research, wined and dined researchers, contributed to political campaigns of sympathetic legislators, and participated in the revolving door between government regulators and industry employment.

A 2017 study examining alcohol industry communications with the public opined that the industry “appears to be engaged in the extensive misrepresentation of evidence about the alcohol-related risk of cancer”.

Three main industry strategies were identified: (i) denial/omission: denying, omitting or disputing the evidence that alcohol consumption increases cancer risk; (ii) distortion: mentioning cancer, but misrepresenting the risk; and (iii) distraction: focusing discussion away from the independent effects of alcohol on common cancers. Breast cancer and colorectal cancer appeared to be a particular focus for this misrepresentation.

Another study documented “pinkwashing”: alcohol products promoted with pink ribbons, partnerships with breast cancer charities, and general terms such as “breast cancer research” or “cure”.

Australian researchers examining alcohol industry trade publications found three “primary themes” evident in the articles reviewed indicating a denial of the risks associated with drinking by the industry: (1) the legitimization of alcohol as an important social and economic product, (2) the portrayal of the industry as trustworthy and benign, and (3) the strategic embedding of alcohol in various facets of everyday life.

This led the researchers to conclude that:

additional regulation of the industry and its tactics will need to proceed without industry acceptance. Clear resistance to increasing consumer protections also points to the futility of inviting industry members to the policy table.

The risks of alcohol consumption are probably not high on the new administration’s health issues “to do” list, and understandably so. Perhaps when things return to normal, if that happens and whatever “normal” may look like then, this effort might gain traction, especially considering the heavy hitters among the petitioners. On the other hand, I’d not bet against the alcohol industry drowning this one before it even reaches the Capitol.

Image: Angie Garrett via Wikimedia Commons.

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Posted by Jann Bellamy

Jann J. Bellamy is a Florida attorney and lives in Tallahassee. She is one of the founders and Board members of the Society for Science-Based Medicine (SfSBM) dedicated to providing accurate information about CAM and advocating for state and federal laws that incorporate a science-based standard for all health care practitioners. She tracks state and federal bills that would allow pseudoscience in health care for the SfSBM website.  Her posts are archived here.