Cancer Warning Labels on Alcohol: Calls for Congress to Act

Kristin Jenkins

February 17, 2021

At a time when Americans are drinking more alcohol than ever before, a group of health organizations is lobbying Congress for a new cancer-specific warning label to be displayed on all alcoholic beverages.

The new wording would read: "WARNING: According to the Surgeon General, consumption of alcoholic beverages can cause cancer, including breast and colon cancers."

The proposal is outlined in a Citizen Petition issued to the Treasury department's Alcohol and Tobacco Tax Trade Bureau.

The petition was filed by three cancer organizations: the American Society of Clinical Oncology; the American Institute for Cancer Research; and Breast Cancer Prevention Partners, in collaboration with the American Public Health Association, the Consumer Federation of America, the Center for Science in the Public Interest, Alcohol Justice,  and the US Alcohol Policy Alliance.

The current health warnings on alcohol haven't changed since Congress passed the Alcoholic Beverage Labeling Act of 1988.

For 30 years, the warnings have focused on the risk of birth defects when alcohol is consumed during pregnancy, and the fact that alcohol can impair the ability to drive a car or operate machinery…"and may cause health problems."

"In light of the strong scientific evidence that consumption of alcohol increases the risk of cancer — including cancer of the oral cavity, esophagus, larynx, pharynx, liver, stomach, colorectum, and female breast — the agency must act decisively and report to Congress on the need for a label on alcohol stating that consumption may increase the risk of cancer," the petition argues.

"Such changes have the potential to save lives by ensuring that consumers have a more accurate understanding of the link between alcohol and cancer, which will empower them to better protect their health," it adds, pointing out that fewer than half of Americans identify alcohol as a cancer risk.

Clinicians' Role

Many adults have limited awareness of the cancer-related risks of alcohol consumption, but will pay attention to their doctor's health recommendations, Farhad Islami, MD, PhD, of the American Cancer Society (ACS), told Medscape Medical News.

"Clinicians could have an important role in increasing awareness of the cancer-related risks of alcohol consumption, which could result in a reduction in alcohol-related cancer burden," he suggested.

Islami was lead author of the first study to estimate the alcohol-related cancer burden in the US on a state-by-state basis, which confirmed that the drinking habits of Americans account for a "considerable" proportion of cancer diagnoses and deaths.

Last year, the ACS issued a new, stronger directive on the use of alcohol, recommending that "it's best not to drink alcohol" in an update of its Guideline for Diet and Physical Activity for Cancer Prevention. However, it retained the  2012 recommendation that men should limit their daily intake to two drinks and women to one drink. 

An ACS spokesperson told Medscape Medical News that warning labels "are in one category of strategies that can help reduce high-risk alcohol consumption."

Message Around Alcohol Is Nuanced

"The messaging around alcohol is nuanced, more so than something like tobacco where we can clearly say 'You should never smoke,' " commented Noelle K. LoConte, MD, associate professor of medicine at the University of Wisconsin in Madison.

In contrast to the clear message about never smoking, she told Medscape Medical News that "for alcohol, it's different."

Alcohol is linked to seven specific kinds of cancer, but not all cancers, and the cancer-causing mechanism is different across these various types, LoConte said. She was the lead author of ASCO's 2017 statement on alcohol and cancer .

Drinking alcohol is also associated with social events and is used as a way to reduce anxiety, or deal with insomnia. "No one wants to hear that something that brings us comfort or joy is bad for us, so we tune out that messaging," she said.

"Alcohol…should be used in moderation," said LoConte, an advocate of policy change. "We should target youth drinking, heavy daily alcohol use, and binge drinking as our best next step in reducing the burden from alcohol-associated cancers."

"Physicians are seen as community leaders. In that role, we should advocate for policy changes to reduce high-risk alcohol consumption and improve the health of our communities," she said.  

When asked if physicians could be doing more to make patients aware of the hazards of drinking alcohol, LoConte was blunt. "We are not doing enough. Doctors need to ask their patients about alcohol use and should be able to offer help to cut down or quit."

In the clinical setting, critical questions remain about the most effective way to counsel patients to reduce their alcohol intake, she said. These questions include whether electronic health records could be a helpful tool, and whether other members of the healthcare team might have a role in patient screening or counseling.

There's also the issue of alcohol use by physicians themselves, especially during the pandemic. "Doctors right now are burned out, over-worked, and stressed. Alcohol is a coping skill," said LoConte.

Doctors who drink heavily "are less likely to discuss alcohol with their patients," she pointed out. Strategies should be put in place to reduce physician stress and improve mental health, LoConte said.

Impact of Warning Labels

Will new labels raise awareness, or even change drinking behaviors?

Clear evidence on the impact of warning labels on alcohol use is lacking, said Michael S. Pollard, PhD, a senior sociologist at the RAND Corporation, and professor in the Pardee RAND Graduate School, San Diego, California.

"Warning labels may have a role to play in increasing awareness of the links between alcohol and cancer risk, but we do not have clear evidence yet for how useful they are for reducing alcohol consumption compared to the research on tobacco products, for example," he told Medscape Medical News.

Others argue strongly in favor of cancer warning labels on alcohol.

"Labeling alcohol containers places the warnings directly in front of consumers at highest risk," said Tim Stockwell, PhD, then director of the Canadian Institute for Substance Use Research (CISUR) at the University of Victoria in British Columbia.

He was involved in the first ever trial of graphic warning labels on alcoholic beverages, carried out in the Yukon in late 2017 and reported at the time by Medscape Medical News.

An alcohol warning label in Whitehorse, Yukon Territory in Canada

"The greater your risk, the more likely you are to be warned. There aren't many strategies that can achieve that," he commented. Without warning labels, he added, consumers of alcohol are left with the impression that "the issue cannot be very important or that the risk cannot be very great."

Stockwell also pointed out that although there is little evidence to show that cancer warnings on alcoholic drinks can be effective, much of this  research has been conducted in the US, with the "standard sized black and white labels with tiny print that hasn't changed in about 40 years."

There is evidence from smoking research that size of type matters. "Health warnings on packages are among the most direct and prominent means of communicating with smokers," notes a review article in Tobacco Control. "Larger warnings with pictures are significantly more effective than smaller, text-only messages."

The trial of cancer warnings on alcoholic drinks conducted in the Yukon had three slightly different wordings, one of which stated: "Chief Medical Officer of Health Advises Alcohol Can Cause Cancer, including breast and colon cancers."

"If ever there was a label that could change behavior, it's ours," Stockwell commented.  

However, four weeks after it began, the project was suspended as a result of pressure from "Big Alcohol." The study resumed a few months later, in April 2018, but the campaign was watered down; the length of the project had effectively been cut in half and the labels no longer carried any reference to the link between alcohol and cancer risk.

Americans Drinking More Than Ever

Meanwhile, Americans appear to be drinking more alcohol than ever before. Since 2011, total alcoholic beverage sales in the US have risen by 30%, averaging an annual increase of roughly 4.3%, and reaching an estimated $252.8 billion in 2019, according to the statistics portal, Statista.

With the arrival of the SARS-CoV-2 virus, increases in economic and emotional distress stemming from the pandemic have been linked to even higher levels of alcohol use.

During the week ending March 21, 2020, which coincided with stay-at-home orders in some US states, market-watch experts at Nielsen reported that national alcohol sales had increased by 54% compared with the previous year. At the same time, online sales of alcohol exploded, increasing by 262% compared with the 2019 baseline. By April 25, 2020, just one month later, alcohol sales had grown to 477% over the previous year.

"In fact, alcohol is the fastest growing e-commerce department among consumer packaged goods, and weekly growth has continued," the authors of the Nielsen report concluded.

A recent analysis of data from a nationally representative sample of 6000 participants in the RAND Corporation American Life Panel has also shown that during the pandemic, Americans are drinking more often.

As previously reported by Medscape Medical News, the 2020 survey showed that when compared with a baseline survey in 2019, heavy drinking in women (defined as four or more drinks within a couple of hours) had increased by 41%.

"Alcohol use is a common way people cope with depression and stress," said Pollard, a study author.

Future research will investigate whether this increase in drinking is an  initial short-term response to the pandemic or whether levels will remain elevated as the pandemic stretches into a second year, said Pollard.

Identifying who is most affected and why will be part of that.

LoConte reported relationships with Celgene, AstraZeneca, AbbVie and Bayer. Stockwell and Pollard have disclosed no relevant financial relationships.

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