Alcohol and cancer: the urgent need for a new message

Alcohol is one of the most widely used drugs in Australia.1 In 1988, the World Health Organization International Agency for Research on Cancer declared it a Group 1 carcinogen — a fact of which few Australians are aware.2 In Australia annually, over 2000 cancer diagnoses and around 1400 cancer deaths are attributable to long-term alcohol use.2 Recent evidence indicates that any alcohol consumption increases the risk of developing cancer, including for the common cancers such as those of the bowel and breast, while smoking and alcohol together have synergistic effects that exceed the risk from either individually.2

This evidence has changed the known risk of developing cancer for a significant number of Australians, particularly those drinking alcohol at light-to-moderate levels, as risk increases cumulatively with consumption over time.2 Most of the Australian population of light-to-moderate drinkers who adhere to the National Health and Medical Research Council (NHMRC) guidelines of no more than two standard drinks daily3 may thus unwittingly be putting themselves at increased risk of developing cancer from their low-level chronic exposure to alcohol. Unlike genetic predisposition or increasing age, alcohol consumption is a modifiable risk factor for cancer, and, therefore, a legitimate target for public health intervention. Conveying this new message to the Australian community is a major public health challenge, but is necessary to educate and inform the community about the long-term alcohol-related risks of cancer, and ultimately, to modify the risk of this serious consequence of regular light-to-moderate alcohol consumption.

Several strategies have been suggested as part of this initiative, including volumetric taxation of alcohol and restrictions on alcohol marketing and promotion.2,4 As part of a comprehensive alcohol-control strategy, one approach deemed to be cost-effective, with high levels of public and political support, is the introduction of mandated health warning labels that include information about the alcohol-related risk of cancer on alcohol bottles and containers.4 Additional measures (such as messages displayed on posters, coasters, or other promotional material at the point of sale) may be required to ensure that the proposed health warning messages reach consumers purchasing alcohol in glasses in hotels, clubs, or bars.5

However, a number of issues need to be addressed to clearly establish the acceptability and efficacy of mandated alcohol labelling. First, any policy mandating alcohol warning labels involves state interference with a third party (alcohol producers), with the aim of changing individuals’ preferences and behaviours, which could be deemed paternalistic,6 embodying a “nanny state” approach. Notwithstanding that alcohol is addictive and intoxicating, such policies are controversial.4 Moreover, it may be difficult to argue that those drinking at light-to-moderate levels are sufficiently compromised, or indeed, sufficiently problematic, to justify intervention.

One of the arguments supporting policies that may be deemed paternalistic is that such policies counter “our cognitive limitations, bounded rationality and weakness of will”;7 when faced with temptation, it is all too easy to reverse long-term rationally derived preferences. So, it may be that alcohol consumption is often not a matter of informed autonomous choice, but reflects an immediate prioritisation of short-term gratification over potential future reward. From this perspective, warning labels may be seen as supporting rational choice, and thus promoting autonomy. Regardless, few would deny that consumers have the right to know the health risks associated with the products they consume.

Second, alcohol plays a significant role in the social fabric of Australian culture, providing economic benefit, enhancing social interactions, and featuring in various cultural activities and traditions. For example, sport (a highly valued activity) is fundamentally linked with the advertising and promotion of alcohol, both at the individual and corporate level.8 The alcohol industry contributes substantially to the Australian economy, through tourism, employment in pubs, clubs and bars, and through sales locally and overseas. Consequently, moves to encourage a reduction in alcohol consumption seem likely to meet with resistance from various sectors of the Australian community including from the alcohol industry itself. This industry has, in fact, argued for self-regulation of the provision of information about alcohol risks through warning labels. Public health agencies, however, point to evidence showing that previous attempts to self-regulate have proven inadequate, and call for mandatory government regulation to ensure consistent implementation of alcohol warning labelling and to enforce compliance.9 Thus, for example, voluntary labelling proposed in mid 2011 by the alcohol-industry-funded organisation DrinkWise was promptly rejected as inappropriate and ineffective by the then Alcohol Education and Rehabilitation Foundation, which then released its preferred versions.9 It should also be acknowledged that plans to mandate alcohol warning labelling will be subject to legislation affecting trade and investment. Some public health advocates have voiced concern that current proposed negotiations (the Trans-Pacific Partnership Agreement) may hinder the development and implementation of effective warning labels.10

Third, it is unclear how effective alcohol labelling will be in modifying behaviour to reduce the risk of harm. There is limited evidence to suggest that warning labels can increase public awareness of alcohol-related harms (with variation dependent on label design, content and demographic factors).9 Further, this awareness may not translate into desired changes in alcohol-related behaviours. For example, some Australian university students have reportedly used information in current NHMRC guidelines about alcohol4 to achieve cost-effective, rapid intoxication.11 Moreover, support for restrictive alcohol policies varies by demographic factors and patterns of drinking, with some evidence for declining support overall across Australia over time.12 It is therefore perhaps not surprising that the recommendation of Cancer Council Australia (that “to reduce their risk of cancer, people limit their consumption of alcohol, or better still avoid alcohol altogether”2) prompted negative mainstream media commentary followed by public responses such as “Pretty much everything gives you cancer these days (apparently) so you may as well enjoy life and have a glass or two of wine when you feel like it!”.13 This kind of statement provides some evidence of a community backlash to attempts to modify alcohol consumption, but systematic social research is required to identify what, how, and in what context commonly held beliefs may work to undermine the effectiveness of health-centred communication about alcohol and cancer risk.

Finally, for the proposed alcohol warning labels to achieve any reduction in behaviour that confers a risk of cancer, individuals must identify themselves as “at risk”. The medical consultation may be one situation within which to inform and explore individuals’ perceptions of alcohol-related cancer risk, but this is unlikely to be easy. A limited evidence base indicates that doctors often do not adequately investigate patients’ alcohol consumption, partly because of their own discomfort and the sensitive nature of the issue — even when faced with evidence of patients’ alcohol misuse.14 It seems unlikely that these factors will be any less influential when raising the issue of light-to-moderate alcohol consumption and the risk of cancer.

We urgently need evidence on how Australians interpret and understand their risk in light of the information about long-term risk of cancer associated with alcohol consumption (specifically including information provided on alcohol warning labels), and how they then negotiate changes to their alcohol consumption. If we are to achieve appropriate modification of alcohol consumption, and a consequent reduction in the incidence of cancer in Australia, this is a crucial component in the design of an effective communication strategy — both in the context of the public health message and the clinical consultation.